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I I l)cpiit\ niilor 

w p/ tIhompson, m.a , 


, F.R.CP. 
MB, DPH 


\OLUMC I 19‘il 
/ 

JA\'UAR\ TO JUNE 


LONDON 

niUTISH MCDICAL ASSOCIATION 
TAVISTOCK SQUART W C 1 





WALPOLE LEWIN, MS, ERGS 

AND 


Sir HUGH CAIRNS, KBC., DM, ERGS 

(From the Dniston of Surgery Radcliffe Infiriiirn Oxford and the Military Hospital for Head Iiiiiiries ll'hcatley) 


It IS now generally accepted that ccrcbrosp nal fluid 
(C5F) rhinorrhoca following a head injur> indicates a 
dural tear in relation to a fracture invohing the para 
nasal sinuses, and that a fascial repair of the torn dura 
IS required as an insurance against intracranial infection 
in the future Most of the fractures insoKe the frontal 
or ethmoid sinuses * In this paper we consider onl> the 
relativelj uncommon group in which the hinorrhoca 
was due to fracture of the sphenoidal sinus Such frac- 
tures are not always detected by radiological cxamina 
tion and a full exploration of this region imoKes special 
problems of exposure and accessibility It seems that 
there are certain clinical characteristics which may lead 
to their detection pre operatively 


Anatom} 

The sphenoidal air sinuses lie in the body of the 
sphenoid bone and arc usually asymmetrical and 



Fio t — The outline of the sphenoidal sinus (inlcrrupled tine) in 
relation to the base of Ihe skull 


separated from one another by a bony septum 
They vary considerably in size and may extend into 
a well marked lateral recess m the great wing of the 

•In exceptional circumslances the fracture involves the petrous 
bone and ihe C S F passes into the nose by way of the middle 
ar and Eustaebian tube (Caims and Lcwin to be published) 


I 

sphenoid Fig 1 drawn from a necropsy specimen with 
the dura intact, shows that the sinus extends forward 
into the anterior fossa, and also laterally beneath the 
optic foramina The sphenoid sinus may therefore be 
implicated by fractures running across the posterior 
part of the anterior fossa as well as bv fractures of the 
middle fossa The close relationship of the sinus to the 
optic nerves and chiasm, to the pituitary body and 
laterally to the carotid arteries is apparent And in 
front of the optic chiasm and the upper part of the 
subjacent pituitary body is the cislerna chiasmatica 
which IS continuous on each side yvith the arachnoid 
sheath of the optic nerv es 

Incidence 

In the years 1938-46, at the RadclilTe Infirmary, 
Oxford, and the Military Hospital for Head Injuries, 
Oxford yve have seen 84 patients yvith cerebrospinal 
rhinorrhoca following closed head injury In 11 there 
yvas demonstrated at operation or necropsy a dural tear 
in relation to a fracture of the sphenoidal sinus Six 
of these, howeyer must be excluded from the present 
examination because they also had other dural tears in 
relation to the frontal or ethmoidal sinuses, and it was 
therefore not possible to say with certainty yvhich tear 
yyas responsible for the rhinorrhoea 

In the other fiye patients the dura yvas tom only over 
the sphenoidal sinus and these cases ire examined in 
closer detail Three patients underwent a fascal repair 
and have remained well since, nearly lour years after 
the operation The other two patients died of pneumo 
coccal meningitis, both in the days before penicillin 
therapy One of these yvas admitted moribund and died 
within 24 hours of admission , the other developed 
meningitis on the day before operative repair was 
proposed, and he died nine days later 

Tlie Fracture 

The sphenoidal sinus may be fractured in several ways 
following head injury 

I After a blow directed to the side of the head the 
skull breaks in the coronal plane cither through the 

4696 



finmsii 

MroicAL Jot RSAL 


- Jan 6 195J SPHLNOIDAL SINUS FRACIURL \vnH RIIINORRHOEA 


coroml ■suture which is sphycd or just behind the suture 
snd anterior to the parictil eminences The fracture 
runs down into each temporal fossa and then across the 
middle fossa to insolve the wall of the sphenoidal sinus 
at the tubcrculum sellac or in the anterior wall of the 
sella turcica (two cases) 

2 A head on blow produces i scscrc central frontal 
fracture with comminution of both walls of the frontal 


'in the dura inaohcd the ethmoidal as well as the 
'•plt'^noidal roof In the five cases in which the dural 
•sir was limited to the sphenoidal sinus area, the tear 
usually only a few millimetres wide and was situ 
ated oscr the tubcrculum sellac or the anterior wall of 
the Sella turcica It probablj resulted from splinterint 
of ihc thin bone in this region 


sinuses from which fracture lines run backwards to 
involve the ethmoid and occasionally sphenoidal 
sinuses In some of these cases there is a large 
central block fracture involving the whole paranasal 
sinus area of both sides (two cases) 

3 The head on blow may be tiken lower down so 
that the bony injurj is predominantly facial resulting 
in a central block fracture of the maxilla, and in some 
cases a fracture of the mandible as well The oserlying 
cribriform plate may be commimilcd This is a frac 
ture which on routine radiography mas seem to be 
entirely extracranial the extent of the d image to the 
cribriform plate and sphenoidal sinus may not be fully 
appreciated unless special radiographic projections of 
the paranasal sinuses arc tal cn through the orbit as 
i'ccasimmarulai' iy" iPNicar i<C'nk'>-a'i* iWr,' nui' jlnhreuir 
•>nd Dutt (1947) (one case) 

4 The abosc are the ways in which the fractures 
occurred m our senes In addition it is possible that 
there may be discrete fractures of the skull limited to 
the roof of the sphenoidal sinus, similar to those which 
base been seen on the roof of the ethmoidal cells at 
operation and nccrop y (Johnson and Dutt, 1947 
Cairns, 1949, Fig 8) 

The Dural Tear — This may be extensise, but we have 
had to exclude from this senes cases in which the gap 


The Ctrcbrospinal Fluid Rhinorrhoca 

lllc outst inding feature of these sphenoidal cases is 
the tiature of the rhinorrhoca It is characteristically 
proflisc In these five patients it was so described, and 
••'■'• It should have been so recorded by different dim 
cian^ renders what is an essentially qualitative observa 
tion ([,c more rehiblc In all pitients the rhinorrhoca 
once begun, continued unabated until operition or 
dcalli^ in one cisc for six months 

Tl>e following case record gives a typical description 
of ihc rhinorrhoL i 

C<>u ' — fins pilicnt sustained a coronal fracture of the 
'•>'•• 11 tin. lcv-1 of the coronal suture following a motor 
ae idem CSr rhinorrhoca was present from the 
time ,1 jufj ^ note made 15 days fitcr reads This 
soldier continues to have profuse C43 F rhinorrhoca when 
cicr ],c t up iind leans over lor tin. Iasi few days il 
has htcn comine down the left nostril only though hitherto 
'• ha, 5 oni times been from the right and sometimes from 
•he left ni tril When the piticnl is lying in the dorsal 
rccur„i,eni >iosiiion he feels find passing down his naso 
phuTmx an I has to swaillow from lime to time Dunng 
•he i,c „ niccp ,t tends at times to get into 

his I'lrynx ai d he is awakened with fits of coughing some 
limes ,,,cfe The patient was sal up this morning and 
within a fivv moments w iiery fluid began to dnp from the 

left nostril— about a drop 



every second or less I col 
hetej 4 ml for cxamina 
non and then let him he 
down 1 thin) the dnp 
would have continued in 
definitely in the sutinc 
position 

In one patient (Case 2) 
a profuse rhinorrhoca 
began one week after the 
injury, at the simc time 
as pneumococcal men 
ingitis niic meningitis 

was treated with intra 
thecal penicillin, but 

showed i marked ten 

deiicv to relapse The 
C S r escaping from the 
nose contained a con 
sidcrable amount of peni 
cilhn and it is not tin 
likely tint the two re 
lapses of meningitis 

which occurred at two 
and four weeks after the 
accident were associated 
with inadequate concen 
trations of penicillin 
within the meninges 
owing to Its continual 
escape with CSF from 
the nose We have seen 
a similar leakage of 



J\N 6, 1951 


British 

MrniCAL JoLPSAi 


3 


SPHENOIDAL SINUS FRAC^I jRC WITH RHINORRHOEA 


penicillin from the subnrachnoid into the subdura' 
space m an infant after head injun (Smi h ct al 
1946, Case S) J 

How common is such profuse rhinorrhoci ? In o 
79 cases of cerebrospinal flu d rhinorrhoca lot due to 
sphenoidal sinus injurj the rhinorrhi a is profuse n 
onlj four cases These patients hu rge tears in n a 
tion to the frontal or ethmoidal su s i ic cxpla la- 
tion of the high incidence of protu c rl i lorrhoea m 
sphenoidal sinus tears must be anat nu. and due to 
the fact that the dural tear establish a c nmunication 
between the cistema chiasmatica and the iij,e By con 
trast the subaraehnoid spaces oser the frontal po' are 
small, so that profuse rhinorrhoca from tears f thcr 
forward is correspondingly uncommon 

The time of onset of the rhinorrhoca after in r> in 
these five patients was \ariable It came on at i iicc in 
two cases, but was delayed seven to ten davs la two 
cases and nine weeks in the remaining case Siiv 'i van 
ability IS seen in all groups of traumatic rhim rhoea 
The onset of rhinorrhoca depends not only on i ic type 
of fracture but also on whether the dural tear is tem- 
porarily sealed by blood clot or brain tissue Tor this 
reason rhinorrhoca after anterior fossa fracti ls ma\ 
begin seven to ten davs after injurv when th oedema 
of the surrounding brain tissue is subsiding t pulped 
brain is Iiqucfrd and the blood clot is undergo g organ 
ization Other factors arc neccssarv to cxpla the very 
delayed onset which is sometimes met with 

Acrocele — With such a ready access tc he basal 
cisterns, atr may enter the cranium tnd seen on 

X ray examination of the si ull In one c for the 

first month after injury air was seen m i le subdural 
space, ventricle and cisterna chi isnutica out not in 
the brain Tig 2 shows the air m this cisb i, and such 
localization should suggest that the dur tear is in 
relation to the sphenoidal sinus 

Other Signs 

Presenauon of Smell — ^Theoretically if the bony 
damage is confined to the sphenoidal si us region and 
docs not extend into the cthmoids the sense of smell 
should be preserved, and this was in fact so in two of 
the four patients whom we have had under investiga 
tion Nevertheless, no absolute reliance can be placed 
on this observation for not only may severe frontal 
sinus fractures occur without disturbance of smell, but 
in apparently isolated sphenoidal cases the olf iclory 
filaments may be damaged cxtracranially pirticularly 
when the brunt of the injury is borne faciallv 

Injury to Neighbouring Slriieiiins — Clinic il evidence 
of damage to the hypothalamus and pituitary gland 
(diabetes insipidus inverted sleep rhythm glycosuria 
or obesity), to the optic chiasm or to the carotid artery 
was present in two of the five cases One patient had 


Paranasal Sinus rractlircs In Closed Head Injun (200 Cases) 
Incidence of Damage lo Parasella Slruclures 


Paranasal 

Sinus 

Fracture 

1 No 

1 of 
Cases 

IIvpo- 

IhaJamic 

Syndromes 

Chhsmal 

Injury 

Carotid 
Aneurysm or 
Fistula 

Cases 

Without fracture of the 






sphenoid 

With fracture of the 

184 

7 

7 

3 

14 

sphenoid 

16 

5 


' 

6 

Total 

200 

12 

to : 

4 ; 

20 


• Sis patienls had a -ombmallon of these symptoms 


diabetes insipidus the other hid a visual field defect 
due to damage to the optic chiasm and also a carotid 
aneurysm The accompanying Table, compiled from 
our 200 cases of paranasal sinus fracture following 
closed head injury shows that, though these neighbour 
hood signs are commoner in the presence of a sphenoid 
fracture they are by no means rare with fractures 
involving the other paranasal sinuses 

Risk of Intracranial Infection 

Three of our five patients developed meningitis in all 
instances pneumococcal, two within a weel of injurv 
and the other sight months later Two of these cases 
occurred before penicillin was available and vvere fatal 
The third patient was treated with penicillin recovered 
from the meningitis and subsequently underwent a sue 
ccvsftil fascial repair of his dura (Case 2) 

In our total senes of 84 cases of cerebrospinal rhinor 
rhoea the incidence of intracranial infection was 19% 
Thus It would seem that the risk of meningitis is greater 
With sphenoidal sinus fr ctures than with fractures of 
the other paranasal sinuses 

The close proximitv of the basal cisterns’ renders 
patients with sphenoidal sinus fracture particularly 
liable to meningitis an 1 dural repair should be done 
as soon as possible Another reason for early opera 
tion IS that if meningitis supervenes and the rhinorrhoca 
IS profuse it may be difficult to establish an adequate 
concentration of pen cilhn in the C S E bv intrathecal 
injections 

Diagnosis and Operative Treatment 

The dillicultics of obtaining a satisfaetorv repair of a 
dural tcir over the sphenoidal sinus may be consider 
able but they can be overcome if beforehand the pos 
sibilitv that the tear is over the sphenoidal sinus has 
been susp"ctcd and the operation has been planned to 
provide a cooj exposure of the sella turcica region 
Radiographic demonstration of a fracture of the 
sphenoidal sinus may be cxtremelv dilTicuIt but this 
lesion should be suspected when in the absence of radio 
logical evidence of a gross fracture of the posterior wall 
of the frontal sinus or of the roof of the ethmoid there 
is profuse rhinorrhoca Additional evidence in favour 
of the sphenoidal location of the trauma is the pres 
cncc of iir m the cistvrna chiismatici, as shown by 
radiographs 

Faced with the possibihtv that the C S F is escaping 
through the sphenoidal sinus region the suigeon must 
be prcpaicd to make a full bifiontal exposure and if 
need be to divide olfactory tracts vvhieh arc functioning 
normally 

The intradural approach for dural repair as used bv 
Julian Taylor (Eden 1942) is the only vv ly by which 
these sphenoidal tears can be fully demonstrated A 
bifrontal flap is turned The dura is then opened along 
the anterior limb of the flap on each side of the sagittal 
sinus, and the inner surface of the dura covering the 
frontal and ethmoid sinuses is inspected for tears first 
on one side and then on the other If no gross tear 
sulficicnt to account for the profuse rhinorrhoca is 
found the anterior fossa must be widely exposed The 
anterior end of the sagittal sinus the falx, and one or 
both olfactory tracts must be divided It is then possible 
lo retract both frontal lobes freely and thus to obtain a 
good view of the optic groove and sella turcica (Fig 3) 


I 



Fio 3 — Case 2 Operation sketch Uifrontal flap diMsion of fnU and mi ittal sums frontal fot Hole in 

anterior wall of sella visible after rcmosal of arachnoid of cistcmn chiasniatica (ft) 11 , fn,,,, (-.) PMch of 

fascia lata applied I tispcu ssnn iiinn 


For full inspection of the anterior wall of the sella it is 
necessary to open widely the arachnoid of the cisterna 
chiasmatica 

The dural tear may be quite small and easily missed, 
and the proximity of the optic nerves and chi ism, and 
of the carotid artery, adds^to the difficulty of the explora- 
tion and of the repair In two of the three cases in this 
series that were repaired the tear was found in the 
anterior wall of the pituitary fossa beneath one of the 
optic nerves , in the third case it lay over the tuber- 
culum aoUae In each case the hole in the dura w is 
repaired with a stamp of fascia lata which lay snug and 
was a owed to adhere by natural processes We prefer 
t'^mporal fascia because it is uniform in 
thickness more pliable and more likely to remain and 
adhere where it has been placed 

Tins method effectively stopped the rhinorrhoea m 
our three cases Four years after the operation all were 
well and working , there had been no recurrence of 
rhinorrhoea and no post operative meningitis 


I he mam fc itui oper^, on arc illustrated b\ 

liic following case 

* n - 

>n' 0 Ucd in a car icciJcnl in 
German! on Ma> b mslaincd severe facia 

'"'"rfrlm ‘•r ".r I’ftns of both cje. i centra 
block frictiirc of iht r p fnctnrc of the nose and 
of the rieht malar anl v, bones and fnelure of 

he 6th thoracic verb,, bid paraljvis of the 

left sixth and seventh I ]]c bled from both 

nostnls and for^^ameK ' j.echarge 

of blood stained C S F , . , , j gmssl) 

impaired at each nostril ' 

The facial fractures v,^ , d after a proph) lactic 

in rathecl injection of ’Op, p^„„,,,b„ Ue>s 

later the patient devclc.^ j. bilateral rhinorrhoea 
and pneumococcal memni ,,„en,ic 

fissure m the sella turcica ^^dl^Era^hs'nkcn dunng 



Jan 6, 1951 


SPHENOIDAL SINUS FRACTURE WITH RHINORRHOEA 


fiRmsn 

Medical Journal 


5 


(he first month after injury showed intracranial air at van 
ous times m the subdural space ventricle and the cislerna 
chrasmatica {Fig 2) The significance of this latter finding 
has already been mentioned 

Operation to repair the dural tear and stop the rhinor 
ihoea could not be undertaken for some weeks The patient 
was down to Oxford from Germany two weeks after the 
accident and at that time he had a relapse of hts menin 
gitis and was developing collapse of his right lung with 
bronchopneumonia which persisted for some weeks When 
ever he was turned on one or other side C S F escaped 
from one or both nostrils, and it was easy to collect samples 
for penicillin studies at two hourly intervals 

By June 22 his general condition was satisfactory for 
operation and his CSF normal though the rhinorrhoea 
was still present Because radiographs suggested a fracture 
into the sphenoidal sinus and had also shown air in the 
cistema chiasmatic i a wide exploration was carried out 
after a preliminary lumbar intrathecal injection of 10000 
units of penicillin A bifrontal bone flap was turned to the 
left The anterior fossa was explored intradurally and the 
dura covering the frontal sinuses orbital roofs and the 
ethmoidal regions looked quite normal The olfactory 
bulbs and tracts also looked normal and though at this 
' stage of his Illness smell had partly recovered on the right 
side it was clearly necessary to sacrifice them divide the 
anterior extremity of the sagittal sinus and the falx cerebri 
and retract both frontal lobes in order to examine thoroughly 
the sellar region (Fig. 3) At first nothing abnormal could 
be seen but when the arachnoid of the cislerna chiasmatica 
was separated from the anterior wall of the sella an area 
of bare wWte bone (0 4 cm in diame(cr) was disclosed on 
the tight side below the optic groove and above the 
diaphragma sellae In tlie right edge of this bare area 
under the medial edge of the right optic nerve was a hole 
through which passed a sleeve of arachnoid containing 
abundant C.S F When the arachnoid was cleared a probe 
could be passed through this hole into the sphenoidal sinus 

The bony hole was plugged with fibrin foam and then 
covered with a stamp of fascia lata A second patch of 
fibrin foam was placed on the anterior wall of the s^a 
between the right optic nerve and internal carotid artery 
(Fig 3) The falx was then stitched bad into place and 
the dura bone and scalp were repaired in the usual way 

Subsequent progress was uneventful The rhinorrhoea 
ceased immediately and did not recur The maxillary frac 
ture which had been treated by internal splinting healed 
in good position The left facial palsy recovered sponlane 
ously and completely but there remained constderable 
deafness of the left car and a scarred but intact ear 
drum The spinal fracture which was treated by a spinal 
jacket consolidated with a wedge deformity His left 
external rectus made no recovery and subsequent opera 
tions on his extraocular muscles in order to banish the 
diplopia were only partly successful 

When seen four years after the accident the patient was 
well and fully employed in administrative work 

In this case the dural tear wax limited to the anterior 
wall of the sella, and so tar as we were able to ascer 
tain so was the fracture The rhinorrhoea did not 
come on until six days after the accident and was accom 
panied by pneumococcal meningitis which relapsed on 
two occasions in spile of energetic treatment with peni 
cillin and sulphonamides Much CSF escaped from 
the nostrils, and with it pemcillm The patient s general 
condition did not permit of operation until six weeks 
after the accident because of his jaw fractures memn 
gitis and bronchopneumonia Anything short of an 
extensive bilateral intradural exploration of the anterior 
fossa would have failed to reveal the dural tear and 
this operation entailed sacrifice of his already partly 
damaged sense of smell The indications for such an 
extensive operation were the profuse character of the 


rhinorrhoea m the absence of radiographic signs of gross 
fracture of the frontal or ethmoidal sinuses and the 
presence of air m the cisterna chiasmatica The final 
result may be regarded as highly satisfactory in view 
of the extensive and severe nature of hts injuries 

Tears in the dura may be multiple hence the surgeon 
must always satisfy himself that the tear which he finds 
IS the one which is responsible for the rhinorrhoea and 
that a dural defect further back vs not being overlooked 
Such a possibility at operation can be envisaged by 
studying, the following case record \ 

Case 3 

In 1938 a jouth aged 18 was involved in a motorcycle 
accident and sustained a compound depressed right fronlo 
parietal fracture comminuting both walls of the frontal 
sinus and the anterior elhmoids on the right side Special 
orbital views were not taken and from the routine views 
there was no suspicion that the sphenoidal sinus was 
involved 

The fracture was elevated at another hospital on the day 
of the accident Cerebrospinal fluid rhinorrhoea tva* 
observed from the riglil nostril on the day after the acci- 
dent and It continued for five weeks and then stopped But 
a month later profuse rhinorrhoea began from the left nostnl 
and continued for six months The patient Was admitted to 
the Radcliffc Infirmary and exploration was advised but the 
day before operation the patient developed pneumococcal 
meningitis from which he died 10 days later 

At necropsy in addition lo the signs of meningitis two 
distinct fractures were demonstrated One linear fracture 
ran down the back of the right frontal sinus where part of 
the bone was missing and the dura was adherent to the 
mucosa but there was no actual tear of the dura A second 
fracture ran across the left optic groove and here the dura 
was lorn and a hole 0 4 cm in diameter led into the 
sphenoidal sinus 

Wc may assume that the rhinorrhoea from the right 
nostril followed the fracture bchind^the right frontal 
sinus and healing finally occurred by ihc dura and stmts 
mucosa becoming adherent The left rhinorrhoea was 
due lo the sphenoidal sinus fracture Owing to seplal 
variations and injury rhinorrhoea from one side ma> 
on occasion result from a contralateral dural tear 
It would have been casj to miss this sphenoidal 
tear with operatise exploration limited to the side of 
the known fracture We do not adsocale bilateral 
exploration in all cases of traiimalic rhinorrhoea There 
arc some cases of frontal and ethmoidal fiacture in 
which the clinical and radiographic signs proside clear- 
cut evidence of a unilateral lesion But whencser there 
IS suspicion that the leakage is through the sphenoidal 
sinus the exploration should be bilateral 

Summary 

In a senes of 84 cases of C S F rhinorrhocs following 
closed head injury n dunl tear over ihc sphenoidal sinus 
was found m 11 (13%) and was the only tear in relation 
to the paranasal sinuses in 5 (6%) 

The mam clinical characteristic of these five cases was 
the protuseness of the rhinorrhoea due to the fact that 
the tear Involved the overlying cistern chiasmatica Another 
sign which may be helpful m diagnosis is the radiographic 
demonstration of air m the cisterna chi ismaiica as m one 
of these cases 

Neighbourhood signs such as CMdence of damage lo the 
hypothalamic region optic chiasm or carotid artery were 
present m nearly half the sphenoid cases but by themselves 
they do not necessaVil> indicate a fracture involving the 
sphenoid sinus The preservation or loss of sense of smell 
is likewise no clinical guide 



6 Jan 6, 1951 


SPHENOIDAL SINUS FRACTURE WITH RHINORRHOEA 


Djuniii 

MrOtCAL JOUHKAL 


Operative repair is urgently indic ited The risk of spread 
of infection intracrannlly into the basal cisterns is nppreci 
ably higher than with fncturcs involving the other paranasal 
sinuses 

Operative repair is difTiciilt and requires a bifrontal flap, 
usually with division of the fal\ and sacrifice of one or 
both olfactory tracts Three patients lindens ent successful 
dural repair and have since been followed for nearly four 
years There has been no further rhinorrhoea or intracranial 
infection and all are well and working 


Rrrransci s 

Caims H (1949) lirttish Medical Journal 1 969 
Calvert C A (1942) Proc h Soc Med 35 805 
Eden K (1942) Dm J Sura 29 299 

Johnson R T and Dull P (1947) Ibid War Surp Suppl 1 
141 

Smith, H V Duthie E S and Cairns 11 (1946) Lancet I 
185 


ABSENCE or THE VASA AS A CAUSE 
or AZOOSPERMIA 

IIV 

KENNETH WALKER, ERCS 
emeritus Surscou lioyal Northern Hospital Consulttnf; 
Urologist Darlforct Hospitals 

AND 

REYNOLD nOYD, ERCS Ed 
Dtnetor Stcnlili Clinus St Johns Hospital Chelmsfortl 
and It anstead Hospital 


The treatment of azoospermia due to a blockage in 
the system of efferent ducts by which the spermatozoa 
reach the posterior urethra is admittedly very unsatis 
factory Tlic commonest situation for such a blockage 
IS the epididymal canal, and when we consider the small 
calibre of this canal, Us length ind the prevalence of 
epididymitis the frcouency with which it becomes 
occluded can easily be understood The next com 
monest site for an obstruction is in the ejaculatory ducts, 
and this is generally the result of recurrent attacks of 
prostatitis and vesiculitis Although the vas deferens 
may also be involved in the infection which brings 
about an epididymitis, a post inflammatory stricture of 
it IS uncommon Genital tuberculosis is an exception 
to this generalization In this disease the lumen of the 
vas is often obliterated, but as the epididymis is still 
more seriously affected this is of no practical import- 
ance When the vas is obstructed it is usually from 
trauma, and the commonest cause is damage inflicted 
on it during the course of an operation such as 
herniotomy 

To diagnose the exact site of the blockage is not 
always an easy task Should there be a clear history 
of bilateral epididymitis and additional evidence m the 
shape of areas of induration at the lower poles of both 
epididymides then it may be assumed with confidence 
that the blockage is in these organs But if there is 
no such history and if no areas of induration are found 
on palpatmg the epididymides, then it is quite possible 
that the ejaculatory canals are at fault 

How IS this supposition to be confirmed or refuted 7 
textbooks suggest that catheterization of the ejaculatory 
ducts should be carried out for this purpose But 
unfortunately this advice is much easier to give than to 


follow Tlie openings of the duets on the slopes of 
the vcnimontanum m ly be so placed tint even when 
clciriy seen it is mechanic illy impossible to pass a 
filiform bougie along them One of us (K. W ) remem 
bers Witnessing an expert it catheterization at work 
and was not impressed with the results of his si ill A 
probe was forced into the lumen of the ducts through 
a direct vision posterior urethroscope employing air 
distension, but such a-manauvre as this was far more 
likely to produce n stricture than dilatation Trauma 
of the ducts must be rigorously ivoidcd 
Anotlier method of diagnosing in obstruction in an 
ejaculatory duct is to expose the vas at the neck of the 
scrotum and to inject into it i solution of indigo 
carmine, noting afterwards whether this has passed into 
the posterior urethra or not Some urologists have 
recommended injection of the vasa also ns a thcr ipcutic 
measure Hicy believe that the tjactil itory ducts can 
be opened up thereby, just is the Fallopian tubes are 
opened up by msiifllation We have never seen a block 
age removed in this way and dislike puncturing vasa 
purely for diagnostic re isons not only because of the 
damage inflicted on a delicate structure but also because 
of the risk of provoling a descending cpididvmitis 
If a case of azoospermia is due to blockage of the 
epididymal canils the only possible remedy is to carry 
out a vaso cpididyniosiomy Although the results of 
this operation arc verv discouraging we cannot afford 
to discard a method which m 10'^ of cases leads to the 
birth of a child ind m 25% to the reappearance of 
spermatozoa in the semen If the patient is prepared 
to accept the gamble and a biopsy has revealed active 
spermatogenesis in tlic testes this opcrition is justifiable 
It can do no harm even if it docs no good Some 
patients on whom we hive operated had previously 
heard that an alternative method of trcitmcntwas avail 
"able Tins was to puncture the testes withdraw 
spcrmatozoi from them ind inseminate with the 
aspirated fluid Such treatment is, for reasons into 
which we do not propose to go utterly useless It need 
not even be considered 

Vnso-cpididv iiiosloniv 

It IS useful, but not essential to give a months pre 
hminary treatment with gonadotropic hormone m order 
to stimulate spermatogenesis and to ensure that the 
epididymal tubes are filled with secretion at the time of 
operating After the testicles have been delivered from 
the scrotum and carefully inspected the vas deferens 
IS separated from surrounding structures at the level 
of the head of the epididymis but great care should be 
exercised not to imperil Us blood supply The vas is 
next incised and some 5 to 6 in (12 5 to 15 cm) of 
nylon thread passed down it to demonstrate its patency 
TTiis thread is left in sttii to act ns a guide and attention 
IS then directed to the epididymis An oval area of the 
tunica covering the underlying distended tubules is 
removed, and when the tubules are incised a drop of 
whitish fluid exudes This is smeared on to a sterilized 
covcrslip and the presence of spermatozoa confirmed 
The finest round bodied straight needle carrying 
40 gauge steel wire, is passed through the wall of the 
vas at the lower end of the incision into it and then 
through the exposed epididymal tubules Having taken 
a good bite of these the needle passes through the vas 
again, but at the upper end of the incision It finally 
emerges through the skin of the scrotum near the root 



Jan 6, 1951 


ABSENCE OF THE VASA AND AZOOSPERMIA 


Britub 

Medicjo. Journal 


7 


of the penis (see illustration) When pulled upon, this 
wire m\aginates the tubules into the lumen of the vas 
During the subsequent healing it also acts as an excellent 
sphnt to the juncture beuteen the vas and the epididymal 
canal The lips of the vasal incision are finally united 
to the epididymis on each side by two lateral sutures 
of 0 005 m tantalum wire The operation is completed 
by returning the testicles mto the scrotum and closing 
the latter, without drainage The steel splinting wire is 
pulled out on the ninth day 
The real object of this paper is not so much to descnbe 
the details of the operation of vaso epididymostomy as 
to call attention to anomalies of the vas which may be 
accidentally discovered in the course of performing iL 



In about 10% of the patients operated on by us either 
no vas at all was found or else the vas was reduced to a 
thread like structure devoid of any lumen Theoreti- 
cally, absence of the vasa might be due to one of two 
causes — congemtal absence or disappearance as the 
result of some previous disease Reference to embryo 
logical and anatomical literature suggests that the 
former cause is an uncommon one 

That the second cause — disappearance through 
disease — is tbe more likely explanation is supported by 
what we found in three or four cases At the,level of 
the neck of the scrotum a vas was discovered, but on 
tracing it downwards it gradually narrowed, and 2 in 
(5 cm ) before it should have joined the epididyims it 
disappeared altogether It was noted that where it 
existed the vas was tortuous, sohd, and very friable On 


cutting mto it a creamy fluid exuded, as though the 
vas was in a state of coagulative necrosis Sometimes 
an opaque hne marked the previous position of the vas 
m that part of its course from which it was absent 
There was nothing m the patients’ chmcal history to 
throw hght on the nature of the disease which had . 
attacked the vasa and had led to their disappearance 

In two patients a somewhat similar condition was 
found m the epididymal canal When seen through the 
tumca covering them the epididymal tubules had a light 
yellowish colour, and when cut into they were found 
to be solid On pressure a fluid exuded sometimes con- 
taining a few spermatozoa and sometimes without them 
Agam it looked as though some form of coagulation 
or fatty necrosis was in progress In yet another two 
cases the vas ended abruptly 2 in above the epididymis 
m a kmd of corkscrew, recalling the termmal portion of 
the normal vas Here, congemtal malformation may 
well have been the explanation 

Conclusion 

What IS the moral to be drawn from these observe 
tions 7 The first and most obvious is that in all cases 
of obstructive azoospermia, and particularly if an opera 
tion IS about to be undertaken to remedy it, the vasa 
must be very carefully palpated through the scrotum 
Every effort must be exerted to make sure that they 
actually join the epididymides Through neglect of 
this precaution one of our patients had been submitted 
to two years of useless hormone treatment by a specialist 
before he came to us for operation It is true that 
m some cases it is difficult to trace the whole course 
of the vasa until they meet the epididymides, but if 
the preliminary examination had been more careful 
some of these exploratory operations might have been 
avoided The second lesson to be learnt is that sterihty 
IS occasionally the result of some pathological condition 
of the vas the nature of which is still obscure It is 
to be hojied that further research will throw light on 
this interestmg problem 


The commercial production of adrenocorticotropic 
hormone in Britain has been in the stage of planning and 
organization for some time under the aegis of the Nation il 
Research Development Corporation the Government agency 
set up three years ago to undertake commercial exploitation 
of Government owned patents and other technical projects 
The three Government departments involved are the hlinistry 
of Health Medical Research Council and Ministry of Food 
which has organized the collection of some thousands of 
sheep cow, and pig pituitary glands weekly from slaughter 
bouses up and down the country solved the problem of their 
preservation and delivered them to the five pharmaceutical 
firms who are co operating in the attempt to produce 
ACTH to the required standards of punty and activity 
One of these firms Organon Ltd has just delivered its first 
batch of product to the Ministry of Health which is rigidly 
_ controlling distribution since supply is far short of demand 
and likely to continue so unless the efficiency of the manufac 
turing process can be greatly raised or a synthetic substitute 
discovered An annual production of 800 g seems the 
probable maximum There is no likelihood of cortisone 
being made in Britain since its manufacture in about thirty 
complicated low yield stages from ox bile is covered by 
American patents and in any case there is probably not 
enough British ox bile available to start with It will be 
recalled that the Ministry of Health recently began monthly 
distribution to 50 hospitals (24 teaching hospitals and 26 
other hospitals nominated by regional boards) of 6 g corti 
sone and 3 g ACTH imported from the U S A at about 
$50 a gramme 


8 Jan 1951 CONTRIBUTIONS Of MODERN GENETICS TO MEDICINE 


B*min 

MrniCJU. Journal 


SOME CONTRIBUTIONS OF MODERN 
GENETICS TO MEDICINE 

DY 

NORMAN f 3 BAILEY, MA 

Slaltsitaan Department of Medicine Unit i ruty oj 
Cambridge 

, Modern genetics stems from the work, published m 
1866 of the Augustinnn monk Gregor Mendel, who 
occupied his leisure b\ growing edible pens in the 
momstcrj girden Mendels work went nlmost tin 
noticed b> his contempornnes, nnd it was noT until 
1900, ifter the ground Ind been prepircd bj the great 
adsmccs in cytology during the eighties and nineties 
thnt Its importance wns rccogni7Cd more or less simtil 
taneously bv de Vries, Correns, and Tschermnt Tor 
just half n century now genetics Ins m idc rapid ind 
constant progress and has found application to the who e 
range of lising organisms from viruses ind bacteria to 
man himself It is with the latter that medical genetics 
has hitherto been mainly concerned though the former 
will probably occupy an increasingly important place 
m the subject 

It IS the purpose of this article both to indieate 
the scope and importance of medical genetics and to 
emphasize the unique opportunities which exist for 
doctors to collect and use gcnctical data The main 
fields of application will bo covered with particulhr 
reference to the practical use to be made of gcnctical 
theory Special attention will be given to methods of 
recording dat i so as to ensure tint the m iximuni 
amount of information can be extracted from them 
and some of the special uses of family pedigrees will 
also be mentioned 

There is no need to do more than make a passing 
reference to the elementary principles on which practi 
cally the whole of genetics is based Both of Mendels 
laws may be summarized under the single heading of 
particulate inheritance according to which the basic 
units of heredity arc material particles — the genes — 
which arc transmitted unchanged from gcncrition to 
generation The first law, the law of segregation states 
that characters arc controlled by pairs of genes which 
segregate or separate from one another during the 
formation of germ cells and pass into dilTcrcnt gametes, 
which contain only half the full (diploid) quota of 
chromosomes and are therefore termed haploid The 
pairs are restored at fertilization Thus the genes arc 
shuffled by segregation and redealt to the next gcncri 
tion Ch iracters controlled by genes may also segre 
gate, and different types will appear amongst the 
offspring in certain definite proportions The second 
law, the law of independent assortment stales that when 
two or more pairs of genes segregate simultaneously they 
do so independently of each other This law has had 
to be modified by the existence of linkage Briefly 
chromosomes and therefore genes m different chromo 
somes are shuffled independently but genes in the 
same chromosome, m which they arc arranged in a 
linear order tend to be handed on together segregating 
and recombining however to an extent which depends 
on their distance apart 

* random element introduced by the 

/ shuffling process the analysis of genetical data must 


incvitibly appeal to the ideas of uncertainty ind prob 
ability associitcd, for cximplc, with polcr or bridge 
With experiment il plant or animal breeding the element 
of uncert iinly can often be considerably reduced by 
using large progenies In man on the other hind not 
only arc families small but it is often difficult to find 
m images between individuals of the ippropriatc genetic 
constitution However, special methods ire availab'c 
for dealing with these diffieultics, and a surprisingly large 
amount of useful Information can often be extracted 
from ipparcntly unpromising d ita 

There IS another fundamental genetic phenomenon 
which must be mentioned , that is, the occurrence of 
mutations Mutation is perhaps most salisf ictorily 
defined as the beginning of a heritable vnnition II 
can be applied to cither genes or chromosomes A 
gene mav suddenly though with extreme rarity, undergo 
a spont incoiis change to a different form, and this 
chingc may be reffected in the characters which the 
gene controls Again chromosomes mav be present 
in abnorm il numbers or a piece of one may breal off 
and cither be lost (deletion), or become reattached the 
wrong way round (inversion) or even joined on to a 
ddferent chromosome ftranslocaiion) Tlic word muta 
tion should be applied only to the act of change in i 
hercditiry unit New genes which suddenly appear 
through mutation arc called ‘ mutant genes and 
the ch iracters to which they give rise ‘mutant 
characters 

Much of the early work on genetics was carried out 
by I H Morgin and his school who bred the fruit 
fly Drasopiuhi mcUmoqnUcr litvrally bv the million 
Tliouqh these studies mav seem somewhat remote from 
medicine, the hereditary meeh ini'ms thus elucidated 
have in fact proved to be of univcrsil application 

Contributions to I’laiit nnd Animal Brccdin}. 

Substantial eontribulions have been made by gcncties 
towards increasing the production of food particularlv 
in the cercil group Considerable increases in the vield 
of miizc Were obtained by using brcedinc techniques 
designed to produce new varieties of hvbrid corn 
Again the manufacture of textiles h is been aided bv 
producing cotton plants with longer and stronger fibres 
and by breeding sheep with heivicr and finer fleeces 
Useful work his also been done on the resistance of 
plants and mimils to pests nnd disease Turthcr 
examples of adv inees in both plant and animal breeding 
could be given almost indcfinitclv 

Medic il Applications 

It IS well known that the rare phenomenon of muta 
tion can be considcrnblv speeded up by x ray irradiation 
Various striins of the mould Pciucillinni were irradiated 
and a search w is mule for high yield mutants The 
process was then repeated, with the result that m less 
than a year a fivefold to sevenfold increase in the yield 
of penicillin was obtained under standard growth 
conditions 

Genetics has also something to say aboiil another 
aspect of antibiotic therapy The genetic study of bac 
tern indicates that strains resistant to penicillin strepto 
mycin and sulphonamide drugs may originate through 
mutation The antibiotic eliminates the susceptible 
bicteria and gives the resistant mut ints a chincc lo 
survive and multiply A thorough understanding of 


Jan 6 1951 


CONTRIBUTIONS OF MODERN GENETICS TO MEDICINE 


BRtma 

Medical Jouwul 


9 


this mechanism will make it increasingly easier to plan 
the clinical use of antibiotics in such a way as to mini 
mize the risk of the development of resistant strains 

Although one of the essential ingredients of the evolu 
tionary process is the variability provided by mutation 
most mutations are deleterious for organisms which 
are fairly well adapted to a steady environment Under 
ordinary conditions it can be shown that most fully 
recessive mutant genes that are capable of detection will 
he latent for thousands of years before becoming mam 
fest However, heavy irradiation of the germ plasm can 
occur through faulty technique in radiology and is an 
even greater danger with the use of atomic energy in 
peace and war This may result in a very great increase 
in the natural mutation rate producing an appreciable 
deterioration in human heredity It is a sobering thought 
to consider that an atomic bomb falling m a highly 
populated region will probably cause more deaths in 
succeeding generations by genetic damage than it will 
at the time of the explosion by blast heat (lash and 
irradiation 

A word should be said about the possibility of using 
experimental animals for the study of comparatively rare 
inherited defects For example canine haemophilia s 
I a sex linked recessive condition as is human haemo 
philia and it is also very similar clinically^ Again 
haemolytic disease of the newborn due to incompati 
bility between the bloods of mother and offspring also 
occurs in certain animals notably mules horses dogs 
and rabbits But so far the analogy with man is not 
complete injury m animals occurring only after birth 
through the absorption of maternal antibody from the 
colostrum When genetic and clinical conditions are 
sufficiently close in both man and a suitable experi 
mental animal it is to be hoped that the far greater 
numbers of the latter available may simplify research 
and lead to substantial advances 

Much of the fascinating work in medical genetics 
has been done on rare abnormalities such as haemo 
philia or Huntington s chorea The number of different 
conditions that have been studied is very large indeed, 
and It is most unlilely that the average student or 
clinician will ever personally encounter more than a 
small proportion of them However, several characters, 
particularly serological ones are by no means 
uncommon 

There are now eight main blood group systems 
ABO MNS, P Rhesus, Lutheran Lewis Kell and 
Duffy, which are apparently inherited independently of 
each other Thus with these and the attribute of sex 
and the ability or inability to taste phenylthiocarbamidc 
(PTC) we may have as many as 10 of the haploid 
number of 24 chromosomes of man distinctly marked 
In searching for linkage these are the characters most 
worthy of examination It is difficult to over emphasize 
the importance of genetics in serology and the extreme 
relevance of this field to everyday problems confronting 
practitioner and specialist alike Common applications 
are to problems of relationship and disputed paternity 


Medico legal Work 

One of the best I novvn elementary cases is that of 
Mrs W, who found on returning home from hospital 
that her baby had on its back a piece of adhesive tape 
bearing the name B The baby at the B house 
was labelled W Had the babies been interchanged 


or had someone been careless with the labels ? The 
bloods of the six persons involved were as follows 


Group 
Mr B AB 

Mrs B O 

Baby W O 


Genoiype Group Genolype 

GAGE Mr SV O gg 

gg Mrs W O gg 

gg I Baby B A GAGa 

I or GAg 


In this table G denotes a dominani gene and g a recessive one 
\yhcn the pair arc identical they are said to be homozygous when 
different (as GAg) they are called heterozygous A recessive gene 
IS one which cannot make us influence felt in ihe individual v. hen 
present with a dominant but which after segregation (separation 
from Us dominant partner) may have the chance to manifest itself 
in Ihe offspring 


There had clearly been an accidental interchange of 
babies before the mothers went home This is doubly 
proved, for Mr B could not have had an O child nor 
could Mr and Mrs W, both of group O, have produced 
an A baby In this extreme case no recourse to any 
other group is necessary The same kind of princip'e 
applies to disputed paternity Although a decisive result 
IS by no means always the case, the use of as many 
blood groups as possible makes such a result very much 
more likely In this country extensive use of the avail 
able knowledge about the inheritance of blood groups 
has not yet been made although considerable steps 
have been taken towards this in the United States Only 
recently a court refused to accept quite definite evidence 
which clearly dispro ed paternity It seems likelj that 
about SO’Jo of the men against whom affiliation orders 
have been made have been wrongfully accused It can 
be shown that by recourse 16 the full series of eight 
blood groups now available abbut 62% of those wrongly 
accused could be exonerated As about 7 200 affiliation 
orders are made eve'ry year and 2 000 men go to prison 
for non payment, it seems that preventable injustice is 
occurring on an appreciable scale 

It is usual for most textbooks to saj that paternity 
tests can only be negative — that they can only on occa- 
sion disprove paternity, and can never provide positive 
-evidence in its favour This was the case when know- 
ledge of blood groups was in its infancy but is no longer 
true with the existence of rare antigens or combinations 
of antigens For example suppose a woman of rhesus 
constitution ede/ede has a baby with the extremely rare 
genotype C''de/cde while the putative father is also 
C"de/cde The conclusion would be irresistible — though 
perhaps not in a court of law In a similar manner a 
number of rare abnormalities might occasionally give 
positive evidence of paternity In 1921 there was 
reported in Norway a paternity case in which a normal 
mother had given birth to i brachyphalangic child 
Brachyphalang) is inherited as a rare simple dominant 
and the court accepted the fact that the putative father> 
was brachyphalangic as evidence of hts paternity 

Now evidence concerning blood groups may be 
required by either party in divorce or kindred proceed 
mgs and a doctor called as an expert witness may find 
himself exposed to the following criticism He may be 
asked Is it not true that genetic factors are subject to 
sudden and unpredictable changes, called mutations, and 
IS not evidence depending upon their inheritance there 
fore suspect f Can it be asserted that the genetic factor 
in question has not in fact changed in this way '> It 
IS essential to be prepared for such opposition and it is 
worth while giving a correct reply here in some detail 
U would run something like this 


The hereditary mechanism of all higher organisms is of 
the particulate or Mendehan type which depends for ils 


10 Jan 6, 1951 


CONTRIBUTIONS OF MODERN GENETICS TO MEDICINE 


Drrii H 

MitrtCAL Jni F^AL 


opcniion upon the extreme pernnnence of the hereditary 
factors themselves Were these to chans,c or mutate in as 
many as one individual in even a few thousand the system 
would break down A study of such miUitions throughout 
the widest selection of living organisms demonstrates that 
a mutation rite of as high as 1 in ^0 000 individuals is 
extremely rare and this frequency is hardly ever exceeded 
Inhentance in man is of the same type and these conclii 
sions are strictly applicable to him However it is un 
necessary to depend on mere analogy for a knowledge df 
human mutation rate It has been possible to study this 
in several instances in which it proved to be when most 
frequent of the same order of rarity ns in other animals 
The error introduced into blood grouping by mutation Is 
very unlikely to be greater thin I in 50 000 and is probably 
less 

Few legal cases can have been decided in the present 
century in which the possibility of mistake was not 
considerably greater than this 

The Rhesus Group nnil Haemolytic Disease 
The importance of ivoiding serological mcompati 
bility in blood transfusion is well known With the 
ABO group one merely has to ensure that the transfused 
erythrocytes arc not agglutinated by the recipient s anti 
bodies With the rhesus group, on the other hand, the 
danger is that a rhesus negative woman may become 
immunized by transfusion or pregnancy, with the con 
sequent risk of haemolytic disease of the newborn in 
her offspring The practical implication that every 
female rcquinng transfusion, or who has or who may 
become pregnant, should be rhesus tested does not of 
Itself involve genetics But in the case of a rhesus 
negative woman for whom one wishes to assess possible 
risks the mvocatiop of gcnctical principles is essential 
It should be noted that the great majority of cases of 
rhesus incompatibility arc in connexion with the antigen 
D although the others (C,C c d o, etc ) may very occa 
sionally stimulate the production of antibody 

When a rhesus negative woman marries a rhesus 
negative man there is no danger, as all the children will 
be rhesus negative (Yhc mating is of type dd x dd ) 
Even if she marries a rhesus povitive man (dd x Dd or 
dd X DD) the risks are still small m spite of the con- 
trary assertions of newspaper articles Provided tlic 
woman has never been transfused or mjcctcd with even 
minute amounts of rhesus positive blood the chance of 
the first child suffering from haemolytic disease is almost 
zero and the chance for the second child still extremely 
small The combined chance of disease in the first four 
or five children is uncertain, but is perhaps no greater 
than 5% if the husbands genotype is unknown With 
homozygous (DD) husbands this chance would be about 
9%, and with heterozygous husbands (Dd) it would 
be only 1 % 

If, however, the woman has already given birth to 
an affected infant, further rhesus positive children arc 
very likely to be diseased and only rhesus negative 
children wiU be healthy If the father is heterozygous 
then there is an even chance of a healthy child at each 
subsequent pregnancy On the other hand, if the father 
is homozygous, all future children are likely to be 
affected , but, even so, there is still some chance that 
a child diseased at birth will respond to treatment and 
eventually be healthy 

Collcctuig Data and Preparing Pedigrees 

It IS a peculiar characteristic of genetic data that they 
are often collected only incidentally during the course 


of work primarily concerned with some other depart- 
ment of medicine More pedigrees of rare inherited 
abnormalities have been pi iced on record by physicians 
in the course of their ordin iry worl than have been 
amassed by research workers making special efforts to 
obtain such material A lot of information of a genetic il 
nature normally arises m clinic il, pathological, and 
socio medical investigations 
Carefully and properly col'ecled fenctic dila have a 
certain permanence iboiit them which is not so charac 
tcnstic of other branches of medicine where new 
methods of observation and experiment frequently make 
older work obsolete Although the svstematic and 
detailed construction of pedigrees is of fairly recent 
ongin, It IS likely that they will be of immense value 
for centuncs to come 

Dcsidcral t for Good 1 nmily Record 

Let us consider some of the special points to be 
observed in Iccping a good family record Clinical 
histones of individuals arc usually perfectly adequate 
for tlicir immediate purpose But when their informa 
tion on hereditary f ictors is later extracted and collated 
It IS only too common to find that vital links in the 
chain of inference arc missing because their relevance 
was not apparent at the beginning 
While there is nlrcidy m existence a vast but relatively 
untapped mine of information in the records of general 
practitioners which could be made to yield valuable 
results if systematically investigated, it is also certain 
that a great deal of promising data would in fact be 
found to be of little use because of the f iilurc to 
observe one or two clcmcnlan precautions in the 
original compilation 

Obviously m reporting an abnormality or disease 
of any kind it is essential to have a full clinical dcscrip 
lion, including such items ns the age and sex of the 
patient, age at onset of the disease variations in seventy 
and frequency of attack, and so on Some indication of 
the patient s social background should also be given , his 
social and economic status, the type of work he does 
etc If IS also important to have this sort of informa 
lion about near relatives, especially parents brothers 
and sisters (sibs), and children It is these near relatives 
that arc the most important — data should always be 
obtained about more distant rUativcs if available but 
this IS not quite so essential 
The usefulness of a family history is naturally depen 
dent on the firm establishment of the clinical diagnosis 
and in the case of the patient through whom the pedigree 
first comes to be noticed (called the ‘ propositus ) this 
will normally have been obtained at first hand It 
often happens that the doctor will be able to see the 
close relatives himself and record his own direct impres 
sions — this IS much the most satisfactory state of affairs 
But sometimes it is possible to secure quite good second 
hand information from the patient himself or other 
relatives — for example about members of the family 
whom the doctor is unable to sec himself In an exfen 
sive study it might be useful to classify the individuals 
in some such grouping as “certainly affected ’ “almost 
certainly affected possibly affected ’ almost ccr 
tainly unaffected, “ certainly unaffected, unknown 
etc But in any event there should always be notes on 
each individual giving the exact evidence itself Should 
it prove impossible to obtain information about nnv 
particular relative of the generations and degrees of 


Jan 6, 1951 


CONTRIBUTIONS OF MODERN GENETICS TO MEDICINE 


British 

Medical Journal 


II 


Unship studied, the reason for the failure should always 
be stated 

When collecting together data on several related per- 
sons in this manner one should" clearly indicate who 
is the propositus — the individual who first brmgs the 
family to notice, or primary case in the genehc sense 
Failure to do this may seriously affect the mterpreta 
tion of genetical data, particularly in the sib method of 
analysis, which is discussed below 

Another vital piece of information which must not 
escape the record is the existence of a consangumeous 
marriage Positive or negative information on this 
point IS equally valuable In many cases it is not 
sufficient merely to state that husband and wife are 
related, that they are cousins for example one wants 
to know m greater detail, for instance whether the 
mother of the husband and the father of the wife are 
brother and sister Cases of twins should also be care 
fully noted, together with any positive or negative infor- 
mation on -whether they are identical or not 
- It is useful to be able to lay out an interestmg pedigree 
"so that the salient chara-teristics may be seen at a glance 
There are various ways of doing this, and some of the 
mam symbols in common use are shown in the accom- 
panying Table In complicated pedigrees especially 


Pedigree Symbols in Common Use 


0 0 42 $^ Oie<i before a 
~ f ' spectfed 


O Femile O O A ^ AfitcteJ 

0 Hale © CQ 

Sex unknown 

^ Number of I dividuals 
^ ihewn collect! e!y 

^ Proposl us 

1 II III Oen rat ons 

1 2 3 Indi fduali n 4 given generation 


Condition unkonwn 


o 0 


Stilfb rth 
Carrier* 


6 i b 


experience of only a certain proportion of all the avail 
able cases If one collects consecutive cases of a 
condition, then the correct proportion of affected indi 
viduals among sibs (which is the most mformative figure) 
is obtained by calculating the proportion among the 
remainder of each sibship ignoring the propositus If 
two members of a single sibship present themselves 
mdependently then that sibship must be counted twice 
over For example, if a sibship consists of four normal 
and three affected mdividuals, of whom two of the 
affected persons appear for examination independently 
while the third is found only as a result of a family 
mquiry, then that sibship is counted twice, each time 
as four normal and two affected 
Two points stand out First, that the right method 
of analysing the data must be employed Second, that 
useful mformation can be obtained from a study of 
sibs only It follows therefore that there is no need 
to be discouraged because of the dffficulty of seeing or 
gammg information about distant relatives It is worth 
making a special effort to obtain detailed information/' 
about parents, sibs, and children, but less than this can 
be of use The same thing is true of data which are 
collected m the hopes of finding a genetic linkage There 
IS not space to go mto these methods now suffice it 
to say that the general principle is to test 
the propositus together with his sibs and 
parents if available for the possession of 
suitable characters other than the one 
used for selection — say, the individuals 
blood groups or their ability to taste 
PTC, etc 


Sibs bore to 
parena 


Huthifld tnd wHe 


6 ^ d 
cT^ 
cA) 


TVfO qsttTs^o 


(Vanml twins 


fetl of a ptiJgrit of pofydactyf/ 



those involving the inheritance of two or more 
characters, special symbols may have to be employed 
For further suggestions, reference may be made to 
Ruggles Gates s Human Genetics vol 1, p 4 
/ 

Ascertainment 

The modern methods employed for interpretmg gene 
tical data normally involve some kmd of statistical 
analysis The reliability of these analyses depends on 
a knowledge of the way in which the material was col- 
lected — what IS usually called the method of ascertain 
raent Uncertainty about ascertainment will affect the 
validity of the results Somehmes it is possible to make 
some allowance for ignorance of the method of ascer- 
tainment, but naturally there is an inevitable loss of 
certainty 

One might in theory collect all the cases of a parti 
cular condition m a given neighbourhood or distnct 
Such a procedure would readily lend itself to simple 
interpretation but would in general be exceedmgly 
troublesome to carry out It is usually possible to gain 


Eugemc Prognosis 

A fev’)' comments on the practical value 
of a knowledge of linkage may be men 
cm rmra tioned here Unfortunately such know- 
ledge IS stdl somewhat rudimentary in 
man, but with the mcreasmg number of 
marked chromosomes especially those 
due to the discovery of new blood groups, 

' quite extensive data on human linkage 
are potentially within our grasp 
Many serious human defects are 
heterozygous conditions, and some of 
them do not become apparent until 
after the normal age of marriage, as m Huntmgton s 
chorea Children whose father or mother has developed 
that disease may wish to marry Though they are 
apparently healthy it is probably undesirable for them 
to do so if between the ages of and 40 they are 
destined to develop' a progressive mental deterioration 
leadmg to insamty which they will moreover transmit 
to half their offspring At present such indivi- 
duals can only be told that the chances are exactly' 
equal they may be afflicted in this way, or they 
and their descendants may remain perfectly noimal 
If, however we knew of a number of genes controlling 
ordinary characters, such as eye colour blood group's 
PTC tashng, attached ear lobes etc , which were linked 
with Huntmgton s chorea, then the situation would be 
much clearer We could say perhaps whether the chances 
of developing the disease or not were very remote or 
very considerable, and this might have far-reaching 
effects on the decisions of the patients concerned Simi 
larly in famihes with sex linked it would be 

invaluable to know whether a 
recessive gene or not 



12 Jan 6, 1951 CONTRIBUTIONS OF MODLRN GHNLTICS TO MEDICINE 


It IS commonly stid tint in hmilics inrboiiring n 
serious rcccssiAC defect no one should mnrr> i ne-iv 
rchtne, tint nnrrnges bttuctn cousins should be pro 
hibited While the ethics of this sort of problem ire b} 
no meins cis), in isscssment of the probibihtics m 
\ol\ed nn> well proside useful puidmcc If there is 
any doubt ibout how to do this the idnec of a com 
potent geneticist should be sought 

Suppose, for cMniplc, i niin Ins Ind i brother who 
died of juscnilc inntirotic idiocy, which is due to in 
lutosonnl recessoe gene (one not on iso\ chromosome) 
and tint he wishes to nnrry Ins fiisi cousin If there 
are no other ciscs of the dtseise in the fimiH then the 
clnncc ihit both the min and his cousin ire hetero 
zsgous is 1 m 6 The clnncc of i single child from 
shell a marrnge being in idiot is therefore 1 in 24 The 
couple mi\ be prepared to iccept this risl but it is 
desirable that lliej should know wh it it is TTic ch mces 
of basing in itTected child arc grcitcr if thes base more 
than one and the probabilitj of producing a hetero 
zjgous child which though itself unallcctcd is cipable 
of transmitting the gene, is considcrabls higher In 
any case a consanguineous marriage ilssays mcrcises 
the likelihood of bringing to light an undesirable 
rcccssisc gene 

To take another case, consider a woman who Ins a 
brother who dies of true haemophilia, which is a sex 
linked reeessne What arc the prospects both for her 
and for another brother who is unaflcclcd The 
unaffected brother cannot carry the gene at all md his 
descendants will all be free of it The ssoman, on the 
other hand has a 50% clnncc of carrsing a gene for 
haemophilia If this is so she will tnnsnm the diseisc 
to half her sons and half her daughters will be earners 
It IS interesting to nolo tint the linkage of the loci 
(gene positions) for haemophilia and colour blindness 
has already been used for eugenic prognosis in f iniihes 
exhibiting both these defects In a certain Dutch famiK 
It was possible to say that the colour blind daughter hid 
a 90 „ chance ol carr\mg a haemophilia gene vslicrc 
her normal sisters h id onh a 10% chance Proba 
biUtics like lUchC arc clearly of much greater saluc Ihm 
the more usual 50% chances as in the previous c\ implc 
No doiibi when the human germ plasm is ns well charted 
as that of Drosophila melanognsicr this kind of irgu 
ment will be used as a matter of course in the proven 
tion of congenital abnormalities 

Aids to Diagnosis and Preventive Medicine 
The discovery of a hereditary factor in the aetiology 
of a disease by no means implies that further medic il 
progress is impossible Heredity and environment inter 
act and determine jointly the condition of a person 
Thus an ailment which depends to some extent on 
heredity may be ameliorated cured or even entirely 
avoided by suitable treatment or alteration m living 
conditions 

There are occasions when a knowledge of hereditary 
background can be used as an aid to diagnosis Tor 
instance a mao was admitted to hospital having lost 
considerable blood by haematemesis The diagnosis lav 
between gastric ulcer cirrhosis of the liver with ocso 
phageal varices and Banti s disease One physician 
however happened to know that the man s father had 
suffered from a mild telangiectasis and had had the 
typical spider s webbing of the nasal mucous membrane 
Now multiple telangiectasis, or Osier s disease is due to 


fiitmai 

Mm cAi. JotfUKAt 

a dominiint gene ind it vv is suggested that perhaps 
the piticnl in question also hid the disease — with a 
tclani leetatic spot m the gastric mueosa The surgeon 
explored, found i I irgc lei ing lett itie focus and excised 
It Svmptevms disappeared md there was no recurrent 
Incmorrhijs If i dominint gent always li is full 
expression then it is true tint no treitmenl vsill prevent 
the be tiers from exhibiting the abnurnnhtv nexerthe 
less some form of tre ilmcnt nnv be available is in 
the suriieil (re iimcnt of polydietvly 
* In either cireiimst incts jenetic Inowlcdgc may help 
to deteet hereditary diseases m their prcchnical stages 
when full advmtigc cm be lalcn of preventive 
me isurcs to forest ill the ippc irancc of niamfcsl disc ise 
Ihuv fimiliil achohirie jitinUice is a dominant, condi 
lion for vvhieh spKiieelomv is a common propHylaei c 
measure Moreover it ein ilways be recognized pre 
clinie ilh by certain I iboralory tests Although it would 
not be feasible to ex mime whole popuhiions of mdi 
vidiials sp-cial cx imin ilion can b,. made of the relatives 
of known siiffercrv When lihoratory tests show an 
■ ndivuhial to be cirrving the gene the spleen can be 
removid if indicitcd and clinical discisc probably 
aveftev! 

Conclusion 

It cm be Slid with full jtislificalion that a deeper 
undersi indini of the j incite il basis of a disease will 
often help to fill m the gaps m a purely clinical approach 
and miy male mitcrial contributions to both trcitnicnt 
and prevention The field of ipplieition of genciies 
to medicine is a wide one There is the study of muti 
tion which has been ipplicd to the ndvnncemcnl nf 
antibiolie iher ipy and wliieh has also emphasized some 
of the dangers ittiched to x ny irradiition and the 
use of itomic energy There is the studv of the 
inherit nice of blood groups .and other common 
characters as in aid to idenufyme individuals parti 
ciil irly m p itcrnitv caves The rhesus blood groups 
are of sp cial interest ind pcnetical thcorv is parti 
culariv vahiible in estimating the risks run by rhesus 
ncguive mothers The possibditv of gaming neyv 
insiclit into various diseases in man bv an invislication 
of closely similar diseases in experiment il inimiK is 
also worthy of consideration Genetics cm be used as 
an aid to diienosis and for sugccsting eertam pro 
ccdurcs m prcvcnlise ^medicine Another important 
application is to eugenic prognosis when one wishes 
to assess some of the dangers att.achcd to parenthood 
where there is the possibditv of heritable disease 

There cm be no doubt that medical genetics has 
a very real contribution to make to the cause of sulTcr 
ing humanity and that its power and seopc yyill crcith 
increase and spread in the ye irs ahead 


In his annual report for 1949 Dr Hiieli Paul medical 
officer of health for Smelhwici. writes It is unfortunate 
that many of these [invesliealtonal] facilities arc only as id 
able lo die priclitioncr llirougli i senior menher of the 
hospii it staff fon example the fcncral practitioner may 
find grcnl difficully in getting tlie rcsull of an cxanlinalion 
of the piticnls blood i baclcriologicai cvimination or a 
radiograph except by making an ippomlmcnt with the 
appropriate consultant in the hospital This max be excellent 
hospital etiquette but it is dc( lorabtc medical practice and 
the technic i! facilities of die hospital particularly those 
issocialed with bicteriology and biochemistry should be 
imnaediaacly available lo the general pracUlioner without the 
intervention of i third person except when the general 
practitioner asks for an opinion as welt as for a lest 



Jan 6, 1951 


PROPERTIES OF ISOPROPYL CHLORIDE 


British 

Medical Journal 


13 


AN INVESTIGATION 
OF THE PROPERTIES OF ISOPROPYL 
CHLORIDE 

BY 

JOHN E ELAM, BA,, MRCS, LRCP 

Anaesiheiist Barnet General Hospital 
AND 

M. L NEWHOUSE, MB, M.RCP 

Assistant Physician Barnet General Hospital 

MacDonald (1950) has described the anaesthetic pro 
perties of isopropyl chloride ( proponesm ’ ) This 
agent has now been used by one of us (J E) in 
approximately 50 cases and has been found to have all 
the properties that anaesthetists have long been waiting 
for The induction was pleasant for both anaesthetist 
'and patient, and with only a gas-oxygen-isopropyl 
chloride sequence the most resistant patient could be 
smoothly led to the deepest plane of anaesthesia with- 
out cough or struggle This anaesthetic seemed td be 
equally successful for both major and minor surgery 
good muscular relaxation was provided and recovery 
was both rapid and pleasant It was noticed that cardiac 
irregularities occurred but as these are not uncommon 
with sodium thiopentone trilene, and cyclopropane, 
they were disregarded In order to avoid these irregu 
larities several patients were induced with gas, oxygen, 
and ether and then a change was made to isopropyl 
chloride, but cardiac irregularities were still noticed in 
each case though the patient suffered no ill effects 
Unfortunately a case of complete circulatory failure 
occurred 

The patient a man aged 48 was a case of moderately 
severe thyrotoxicosis Before operation he had had five 
weeks rest in bed and three weeks premedication with 
Lugols iodine Electrocardiograms taken three weeks 
before operation showed sinus tachycardia but no evi 
dence of myocardial damage Under treatment he had 
gamed 5 lb (2 3 kg) m weight and his pulse rate fell 
from a range of 120-110 to 90-80 For the induction 
of anaesthesia the nitrous oxide-oxygen-isopropyl chloride 
sequence was used The induclion was very smooth and 
quiet The patients colour was good throughout and 
at no time was there any indication that some difficulty 
might arise An endotracheal tube was passed very easily 
and the patient taken into the theatre Just 10 minutes after 


the induction was started as the patient was being lifted on 
to the table he gave a slight cough and his colour changed 
to ashen grey he was found to have complete cardiac 
arrest Controlled respiration with oxygen was continued 
Ihroughouf the attempts to restore him Cardiac massage 
with intracardiac injections of adrenaline and procaine were 
given and after 45 minutes the heart was restarted but he 
died a few hours later (Roualle 1950) 

After this experience it was decided that electro 
cardiographic records should be obtained during the 
admirustration of that anaesthetic For this, two healthy 
young men were chosen Only nitrous oxide, oxygen, 
and isopropyl chloride were used 

Case 1 — The patient was a man aged 31, and the opera 
lion was for the lemoval of a semilunar cartilage The 
preliminary record was normal (Fig 1) thereafter records 
were taken at approximately five minute intervals, and more 
often when the pulse was irregular (Fig 2) After five 
minutes Lead II showed a regular rhythm but with suppres 
Sion of P waves and depression of the S-T interval at 11 
minutes a curious rhythm had developed with dissociation 
of the auricular and ventricular elements The P waves 
were absent for several beats and then appeared with no 
constant relation to the QRS complex there was a high 
degree of A-V block and possible nodal rhythm At 17 
minutes the rate was 200 a minute and there were multi 
focal ventricular extrasystoles , at 19 minutes the rate was 
100 and irregular with absent P waves suggesting auricular 
fibrillation A Trontinuous record was then taken which ^ 
showed variations between multiple ventricular extrisystoles 
to a coarse auricular fibrillation Five minutes later he 
reverted to a normal rhythm which continued to the end 
of the operation 

Case 2 — ^This patient was a man aged 25 and the opera 
tion was for the repair of the flexor tendons of the right 
hand A normal record (Fig 3) was 
obtained before the administration of 
the anaesthetic Under the anaes 
thetic he showed less severe changes 
than the first patient but (Fig 4) at 
five minutes the rate was 120 a 
minute with multiple extrasystoles 
and depression of S-T intervals m 
some complexes Extrasystoles were 
still appearing in the record taken at 
seven minutes At 10 minutes the 
pulse rate had dropped to 60 and was 
sti/1 slightly irregular but there were 
normal contractions At 25 minutes 
and at the end of the operation after 
45 minutes anaesthesia the rhythm 
was normal 



Fio 3 — Case 2 
Pre anaesthetic 
record normal 
tracing ^ 



Fig 1 — Case 1 
prc-anaesihctic 
record normal 
tracing 


5 Mms 


Lcdil H M Min^ 




Udd H 


- 




17 Dm, 


Le,.d E 19 Mins 


Uadi 20 Mins 




•'l,' 


Lead I 


w- 


€1 


j j* i 


Lead M 30 Mins Ua dE 


' r i .Li 

I. 7 ^ , 








Flo 2 — Case 1 Consecutive rccoids while under anaesthesia (a) Depression of S-T inteml and 
absent P waves (5) Dissociauon of P waves and QRS complexes Possible nodal rhythm (c) Mulu 
focal ventricular extnsysiolcs rale 200 (d) Auncular fibrillation rale 100 fe) 

with two heals showing increasing P-R jntervaL (/) Coarse auncular to 

normal rhyihm 





16 Jan 6, 1951 


PYRUVIC ACID LLVCL IN DIABLIIC ACIDOSIS 


,, Cwuii 
MtmcXL JCKASAL 


INDIVIDUAL OBSERVATIONS 



no 2 — mi m pynuic ncid locls irt 
four patients ind fall in blood su(,ar and 
nse m alkali rcserac in two patients in 

which ihtse were followed X X 

= control patients O O = cocarb 

oxylasc treated patients 


cocnrbox>l tscand 
riboflaain in the 
t r c 1 1 ni c n t of 
dinbctic acitlosis 
h istens the rite 
of clinical re 
coverv and the 
return to normtl 
Il\l 1 of the blood 
p\ru\ic acid and 
ilL ill reserve We 
found the r lie of 
improvement to 
be similar to that 
seen in pnred 
controls b"cn 
identic il treat 
menl with fluids 
ind insulin with 
out the addition 
of coc irbo\)lasc 
ind riboflavin 
neither in the 12 
alloxan - diabetic 
ribbits nor in the 
4 acidotic diabetic 
pitients was there 
in> difference in 
the rate of clmi 
cal recovery the 
f ill in blood 
P)ruvic acid ind 
blood sutar or 
the rise in ilLah 
reserve 

T he test of 
such a treatment 
in human patients 
IS of course, more 
diflicult since 


comparisons arc valid only when comparable eases arc 
contrasted , this was more easily achieved with the 
rabbits than with the patients Thus while we have 
confirmed the evidence of defective pjruvic acid o\i 
dation in diabetic acidosis we found no evidence that 
this was due to a deficiency of cocarbo\)lasc Normal 
pyruvic acid metabolism requires not only cocarboxy 
lase and other co enzymes but also the intcgrit> of the 
enzyme protein it may be that in diabetic acidosis the 
protein component of the enzyme system is inhibited or 
partially inactivated as it is in sodium arsemte poison- 
ing (Peters, Sinclair, and Thompson 1946) 


Summary 

The blood pyruvic acid level was found raised during 
diabetic acidosis in 12 alloxan diabetic jabbits and 4 acidotic 
diabetic patients 

Supplementing a standard treatment for diabetic acidosis 
by cocarboxyla^ (vitamin B, diphosphaie) and riboflavin 
did not appear to accelerate further the recovery from 
diabetic acidosis as measured by the rate of the fall of the 
raised blood pyruvic acid level the fall of the blood sugar 
the rise of the alkali reserve or the observed clinical improve 
ment 


We wash to express our thanks to Dr Russell Fraser for his 
help and advice to Dr F Wngley for suggestions and to 
Miss Shirley Looker for her assistance with the biochemical csti 
mations We are also indebted to the Diabetic Association for 
the grant of a Lund Research Fellowship to one of us The 
cocarboxylaso used in the investigation was kindly supplied by 
Roche Products Ltd 


Rertarsers 

Banpa^^I, Ochoa, S, and I’clcrs R A (1939) Dhehem J 33 

Boiilin R Uhry P Meyer F W„ and Bonfils S (1949) Pr 
ni^d 57 6^9 

Biicdin),, I Worlis 11 I I cm H D and Lsturonne D (1942) 
Amrr J mrd id 204 S38 
Dultv L (1945) J lalh Had 57 199 
I ncdcniann T I and Haugen G L (1943) J blol Chem 
147 41 V 

Gooilliatl, R and Sinclair If M (I9-.0) Ibid 132 II 
Guest G M (1942) Amirr J Dli Child 64 401 
king, L J (1917) MtcroandyjU in Medical Ihucheintttry 

Oiiirchill I ondon 

Matkees, S (19)9) 7 Urn Mrd 145 354 

am) Meyer J VV (1945) I xprnertna 4 31 19V 

(1949) Srh»rL mrd Wirht 79, 931 

Martin H I and Weriman M (1947) J elm Inirjt 26 217 
Peters R A Sinclair II M and Tliompson R II S (l9-,6) 
Utorhem J 40 VI6 

Van Slyke D D and Cullen G E (1917) J blol Chem 30 
289 


ORAL rLNICrLLIN IN CHILDREN 

iia 

S A DOMADIS, MD 

Senior / tcliinr in Child Ilrilth Unierniy oj Sheffield 

JOHN L. IMIR\, MD, DCH 

Clinnal I'lilhtdoiisl Lecltirrr m ffiillwlogy Unnersid 
of Sheffield 

AVD 

SMI IIA M SlLSSARl, I) Sc 

III clrriido^ist Penionrtriilnr in hi.cirriolop'i Uinersit\ 
of Sheffield 

(I roni the Childrens Hospital Sheffield) 

It has been shown Ih it sitisf ictory bacteriostatic blood 
levels nrc altnincd in infants by the oral administra 
tion of penicillin (Henderson and McAdam 1946 
Buchanan, 1946 Ilusson 1947 Moseley I94S) The 
oril use of penicillin in infants has therefore been 
widely adopted In older children and adults (he condi 
lions for absorption of penicillin from the gastro 
intestinal tract art not equally favourable probably 
because of the higher gastric nciditv 

Charney ct <il (1945) suggested the use of an antacid, 
and It was shown (Gydrgy ct etl 1945, Burke cl al 
1945 Cohlan c( o/ I94S Hildick Smith ef o/ 1950) 
that the combination of penicillin with an antacid is 
cITcctivc in maintaining a bacteriostatic blood level 
Hoffman cl al (I94S) were unable to confirm this They 
obtained satisfactory results by giving penicillin three- 
hourly m a dose of 1,400 units per lb (450 g) of body 
weight All authors agree that penicillin should be given 
on an empty stomach to ensure maximal absorption 

Owing to the conflicting reports on the oral dose 
required and on the value of antacids it was felt that a 
study of these points was necessary before penicillin 
could be used by mouth for therapeutic purposes 

Methods 

Seventy SIX children aged 2-15 years were given peni- 
cillin two or more hours after a light breakfast It 
was in tablet form each containing 200,000 units Tlie 
dose given varied from 1,000 to 7,000 units per Ib of 
body weight Sodium citrate, 3 g m 1 oz (30 ml ) of 
flavoured water was used as antacid It was given 
immediately before or after the penicillin 



Jan 6, 1951 


ORAL PENICILLIN IN CHILDREN 


BMTCH 

Mxsioll Journal 


17 


'The blood and penicillin serum levels were estimated 
by the capillary tube method described by Fleming 
(1943), using whole blood inoculated with Richard s 
stram of Streptococcus pyogenes The serum used for 
assay was from capillary blood collected m Wrights 
capsules Blood was taken before the penicillm was 
feiven and three hours later In many children blood 
_was also taken at other intervals A total of 208 test 
doses Were given, involving 632 pemciUm assays 

Results 

The Table shows the number of children grouped 
accordmg to the pemciUin dosage and the use of 
antacid, with the numbers in each group havmg a serum 


penicillin for only a few hours every day mav hate 
therapeutic effects the aim of most penicillin regimens 
in chmcal practice is still the attainment and mam 
tenance of a bacteriostatic blood level for the whole 
period of treatment ' On this basis the results of the 
present work are discussed 
Hoffman et al (1948) claimed satisfactory results with 
unbuffered penicillin with single doses as low as 1 400 
umts per lb of body weight, and they recommend this 
dose at three hourly intervals but a study of their data 
reveals that of 137 children aged 1 to 12 years 41 had 
a blood level of less than 0 03 unit per ml three hours 
after the oral dose With a shghtly higher dosage this 
level was found in 11 out of 85 children 


Number of Children with Serum Penicillin Le\el of 0 06 unitlml or More at Various Times after Ingestion of the Drug 


Ho«n After loge^tton of Penicillm 


\b of 




Wiihom Antacid 




With Antacid 


Weight 

0 


I 


2 

3 

4 


0 

2 

3 

4 

1 000-1 999 
i.000-2,999 

0 of 20 

7 of 7 

11 of 12 

10 of 12 

9 of 20 

0 of 12 

0 of 12 

0 of 18 

0 of 20 

9 of9 

g of16 

16 of 20 

0 of9 

3 000-3 999 

0 of 20 

3 of 3 

5 of 

.S 

3 of 5 

13 of 20 

Oof ^5 

0 of 2 

0 of 20 

5 of 5 

19 of20 

I of5 

4 000-4 999 

Oof 20 


6 of 

6 

5 of 6 

16 of 20 

Oof 6 

0 of 4 

0 of 20 

6 ofd 

19 oftO 

I of6 

5 000-5 999 

Oof 20 


6 of 

6 

13 of 13 

16 Of 20 

5 of 13 

2 of 6 

0 of 20 

1 of 1 

19 of 20 

1 ofl 

6000-6 999 

Oof 30 


7 of 

7 

7 of 7 

29 of 30 

7 of 7 

2 of 7 





pemciUin level of 0 06 unit per ml or over at various 
tunes after the mgestion of the drug 
The level of 0 06 unit per ml of serum was considered 
the immmum necessary for satisfactory therapy in con- 
ditions usually treated with penicillm In this, as m 
previous works, the serum level three hours after the 
mgestion of the drug was arbitrarily chosen for the 
evaluation of this method of pemciUin administration 
It can be seen that in the groups of children receivmg 
less than 4,000 units per lb of body weight without 
antacid only 22 of 40 (55%) had an adequate bacteno 
static level at three hours Of the 40 children receiving 
4,000 to 5,999 units per lb of body weight without 
antacid, 32 (80%) had a bacteriostatic level three hours 
after the administration of the drug Finally, in the 
group without antacid, 29 of the 30 children (97%) who 
received 6 000 to 6 999 uniU per lb of body weight had 
a level of 0 06 unit per ml or over at three hours 
When antacid was given together with the penicillm, 
9 of 18 children (50%) receiving 1 000 to 1,999 umts 
per lb of body weight 35 of 40 children (87%) receiv- 
mg 2 000 to 3,999 units per Ib of body weight and 
38 of 40 (95%) receivmg 4 000 to 5,999 per lb of body 
weight had a bacteriostatic level three hours after takmg 
the penicilhn tablets 

Fifty seven children received the same dose of peni 
cilhn on two occasions the first time without antacid 
and the second time some days later with antacid ill 
the other conditions of the test being exactly the same 
In 42 children the bactenostatic level at three hours was 
the same on both occasions — namely either above or 
below 006 umt per ml (in 3 below m 39 above) Four- 
teen children had a level less than 0 06 unit per ml 
at three hours without antacid and a level of 006 umt 
per ml or more when antacid was given One child 
had a level of 0 06 without antacid and a lower level 
with antacid 

Discussion 

Although it has been suggested (Jompsett et al 1949) 
that the mamtenance of bacteriostatic blood levels of 


Similar results with unbuffered preparations and doses 
of approximately 1 SOO to 3,000 units were obtained by 
Reisman et al (1947), Cohlan et al (1948), and Hildick- 
Smith er al (1950) 

In this mvestigation an attempt has been made to 
estimate the amount which had to be given m order to 
obtain a serum level of at least 0 06 unit per ml three 
hours after penicillin was taken The results show 
that even when the dose given by other investigators was 
doubled (4 000 to 5 999 units per lb of body weight) 
8 of 40 children (20%) had at the end of three hours 
a serum level of less than 0 06 umt per ml 

It was only when 6 000 to 6 999 units per lb of bodv 
weight were given orally that the desired effect was 
achieved in all but one of 30 children (97%) It would 
seem that doses smaller than 6 000 umts per lb without 
antacid cannot be relied upon to maintain a bacteno 
static serum level of at least 0 06 unit pi-r ml over a 
period of three hours 

According to Reisman et al (1947) and Cohlan et at 
(1948) the 'addition of antacids did not improve the 
results when 50 000 to 100 000 umts were given to 
children aged 2-12 Hildick-Smith e/ a/ (1950), admmis 
tenng a dose of approximately 3 000 umts per lb of 
body weight with an antacid obtained blood levels of 
008 umt per ml or over in all 10 children at the end 
of three hours 

The experience from the present senes demonstrates 
the value of simultaneous administration of an antacid 
With a dose of 2 000 to 5,999 units of pemcilhn per lb 
of body weight a blood level of 0 06 umt per ml or 
over was obtained in only 54 of 80 test doses (67%) 
without antacid compared with 73 of 80 test doses 
(91%) when antacid was given 

The companson in individual cases of the results with 
and without antacid, but on the same dose, further 
demonstrates this point Of 57 children thus compared 
14 had a satisfactory level at three hours only when 
an antacid was given, but m one the effect was the 
opposite 



lb Jan 6, 1951 


ORAL PLNICILLIN IN CHILDREN 


Midjcal JOVUNAL 


It IS difTicuIt to cstimite the magnitude of the economy 
in penicillin achieved by the addition of an intacid 
The results show that, when no antacid is given, at Icist 

6.000 units of penicillin per lb of body weight must be 
administered to ensure a level of 0 06 unit per ml or 
over at three hours in more than 90% of the children 
When an antacid is given the minimal dose likely to have 
a similar effect, ns it appears from the table, is i 000 
units per lb of body weight On this basis the addition 
of an anticid would permit a reduction of approxi- 
mately 50% in the dosage of penicillin 

It IS gencnily advised that if penicillin is given orally 
the dose should be three to five (Ponchcr and Unna, 
1950 , Gyorgy and Lee 1947) or four to eight (Hcrrcll, 
1949) times larger than the parenteral dose , As the 
recommended single dose for parenteral use in mild 
and moderate infections is 500 units per Ib of body 
weight (or 4 000 units per lb per 24 hours in eight doses) 
even an eightfold increase in dose is inadequate for 
oral use When no antacid is given nothing short of 
12 times the parenteral dose can be trusted to produce 
satisfactory blood levels in most children This would 
mean that a 10 year-old child would need more than 

1.000000 units of penicillin a day, oimoicthan 1,500000 
units if m antacid vverc given at the same time Another 
disadvantage is the three hourly administration Tins 
method of giving penicillin must therefore be weighed 
against the parenteral injection of a slowly absorbed 
preparation such as procaine penicillin in 2% aluminium 
monostcarate which is cfTcctivc if given once every 
24 or 48 hours (Emery ct a! 1949) 

Summary 

Blood levels of penicillin after oral administntion of the 
drug with and without an antacid have been estimated in 76 
children who vverc given 208 test doses 

To attain a reliable bacteriostatic level of 0 06 unit per 
ml three hours after the ingestion the single dose of pcnicil 
hn should be not smaller than 6 000 units per lb of body 
weight — that is 48 000 units per lb of body weight in 24 
hours 

Simultaneous administration of an antacid may allow \ 
reduction of this dose by approMinatcty 50% 

We would like to thanl Mrs E L Henderson matron of Ash 
House Hospital School and licr nursing stall for tbcir co opera 
tion and assistance The penicillin tablets were Itndlj supplied 
by Glaxo Laboratonvs Ltd Greenford Middlesex 


RcrcRENcns 

Buchanan J L (1946) Lancet 2 '60 

Burle F G Ross S and Strauss C (1945) / Ainer med 

/Iss 128, 83 

Chamey J Album H E and Bcrnlnrt F W (1945) Science 
101 251 

Cohlan S Q Lewis J M and Scligman E (1948) Amcr J 
Dis Child 75 15 

Emery J L Rose L M Stewart S M and Wayne E J 
(1949) British Medical Jotirncil 1 1110 
Fleming A (1943) Laiieet 2 434 

Gyorgy P and Lee H F (1947) Adiances in Pediatrics 2 
151 Interscience Pub) New York 

Vandergrift H N Elias W Coho L G Barry F M 

and Pilcher J P (1945) J Amcr rued /Ijs 127 639 
Henderson J L and McAdam I W J (1946) Lancet 1 922 
Herrell W E (1949) In Brennemann s Practice o) Pediatries 
rr „ v^bapter 44 Prior Hagerstown 

^ ~ F McNair and Wtntlock C M 

Pedialr 32 1 ^ ^ ^ 

Husson G S (1947) Ibid 31 651 

CIiiM/i 23 93 

™ P I" Mitchell-Nelson s 

lextbooK of Pediatrics 5th ed Saunders Philadelohia 
V Reisman H A^^^Goldfarb A A and Molloy^M (1947)'^ imer 

^°'"tia 4 qv^ A Goldstein O and McDermott W 

U949) J Ainer med Ass 139 555 


INSTILLATION OF STREPTOMYCIN 
INTO THE PERICARDIAL SAC IN 
rURERCULOUS PERICARDITIS 

ID 

R 1> K COE, MD, MR CP 

< piisiiliinf, l'li}sician II rvf MIddItsex Hospital lair 
Medical tlifisirar St Heller Hospital Carshallon 

Several eases of tuberculous pericarditis treated with 
sirtptomvcin by the intramuscular route have been 
ri-porttd m the literature Reference is made in a report 
of the Mcilical Research Council (1950) to one ease of 
tuberculous pericirdiil cllusion in which streptomycin 
w IS injected into the pericardial sac, but no details or 
dosige were given T ipic ii al (1950) also report the 
ease of I man of 4f with chrome pulmonary tuberculosis 
who developed a pcrieardial cITusion Tlicy gave five 
injections of streptomycin totalling 1 15 g, into the 
pericardial sac vvilhoiit obvious improvement 

fhe following case is recorded because it shows that 
strcplomycuv injected into the pericardial sac, in con 
junction with streptomycin hy the intramuscular route 
constitutes a sife ind rational form of treatment in 
tuberculous pericirditis with effusion, and that it mav 
be bcncficiil, csficcnllv in eases characlerircd by rapid 
re iccumiihtion of fluid iftcr paracentesis 

C we Report 

A Post OlTicc clcclncian aged 20 whose brother was sulfer 
ing from a pleural effusion vv is found to have enlarged 
Ildar glands on mass radiognphy in September 1948 He 
w-is asked to ittcnd for further radiological examination 
but did not do so On J iniiarx 8 19*9 he developed sub 
sternal pun mal ii'c fever ind vomiting and two vveekv 
later was admitted to hospital 
Examination on admission on Januiry 22 revealed a well 
built pale ill min moderately dyspnocic and with a tern 
pcraliirc of 103 2 F (39 s C) There wax pulsus piridoxus 
and moderate engorgement of the neck veins the apex beat 
was jivst palpable in the fvCtlv left space m the mid-clavicuht 
line and cardiac dullness extended from 1 in (2 5 cm ) out 
side the riclil sternal border to the mid axillary line Pen 
cardial friction was beard over a wide area of the prac 
cordium I here was m area of dullness with bronchial 
breathing and increased vocal resonance over the left lower 
chest posteriorly near the midlinc The blood pressure was 
130/70 

Diagnostic pericardial paracentesis on J iniiarv 26 yielded 
dark straw coloured fluid which grew Ulscohariiritim 
iitlierciilosis on guinea pig inoculalion but direct examination 
and 1 ovvenslein ciilliire were negative 
On January 30 be developed cardiac tamponade and 
32 or (907 ml) of fluid was aspirated with immediate relief 
of symptoms Signs of tamponade returned however in 
24 hours and a further 22 07 (624 ml) was aspirated the 
following day Wilhin the next two months recurrent 
tlmponade necessitated five further aspirations and amounts 
varying from 14 lo 32 oz (397 to 907 ml) were amoved 
on each occasion 

Intramuscular streptomycin 0 5 g twice davK was started 
on February 12 and alilioiigli this resulted in some lowering 
of the temperature the pericardial effusion continued to 
accumulate at about the same rate as before It was there 
fore decided to give streptomycin into the pericardial sac 
On March 24 1 g dissolved in 2 ml of water was injected 
into the effusion The procedure was repeated weekly for 
another five weeks No adverse effects occurred and after 
the third injection there was a considerable drop in fever 



Jan 6 1951 


STREPTOMYCIN IN TUBERCULOUS PERICARDITIS 


BjimsH 

Medical Journal 


19 


The fluid re formed very slowly only 6 oz (170 ml) being 
aspirated on two occasions after beginning treatment (see 
Chart) 

On April 21 he de\ eloped a left sided pleural effusion 
which was aspirated several times Intramuscular strepto 
mycin was stopped on May 2 because ot toxic symptoms 

On May 3 there were signs of superior mediastinal obstruc 
tion and a large mass of enlarged meJiastinal glands was 
seen on radiological examination Two weeks later ascites 
oedema of the legs and enlargement of the liver to 3 in 

FLUID 


(7 6 cm) below the costal margin were present All these 
manifestations were unaccompanied by any notable recur 
fence of fever or toxaemia and they slowly subsided with 
rest in bed over the course of the next six months 
When last seen (May 6 1950) the patient was extremely 
well and back at full work and was able to walk five to 
SIX miles (8 to 9 7 km ) at a bnsl pace without dyspnoea 
Radiologically there was moderate enlargement of the 
cardiac shadow with slightly diminished cardiac pulsation 
and still some enlargement of the hilar glands on the right 
side The blood sedimentation rate was 2 mm per hour 
(Westergren 200 mm ) 

I wish to thank Dr J B Harman for permission to publish 
ihis case 

References 

Medical iCesearch Counal (19^0) Lancet 1 841 
Tapie J Laporte J Pmel and Monnier (1950) Pr med 58 
226 


Medical Memoranda 


Perforated Peptic Ulcer of Meckel’s 
Diverticulum 

A case of Meckel s di\erticulum containing gastric 
mucous membrane ''nd presenting with perforation 
of an associated peptic ulcer is described The salient 
features are discussed with special reference to the occur- 
rence of peptic ulceration m these cases 

Case Report 

A girl aged 7 was admitted to the childrens ward of 
Grantham General Hospital at I pm on No% ember 14 
1948 She had always been healthy until three days before 
admission when she began to complain of diffuse vague 
abdominal pain It was noted that the stool soon after the 
onset of the pam was dark red On the day before admts 
Sion two small stools of similar colour were agam passed 
and on that night the pain became more se\ere and was 


definitely colicl y in nature doubhng the patient up and 
preventing sleep A small amount of yellow fluid was 
\omited two hours before admission and the pain then 
continued as a dull central abdominal ache There were 
no urinary symptoms The bowels had been regular before 
the onset of the pain 

On examination the temperature was 101 F (38 3 C) 
pulse 140 and respirations 24 ^ The abdomen showed 
generalized rigidity maximum o\er the lower right rectus 
and right iliac fossa Tenderness was present over the 
central part and right side of the abdomen 
but there was no h\peraesthesia Rebound 
tenderness was also present There was 
dullness to percussion in both flanks and 
shifting dullness could be demonstrated on 
moMng the patient to one side or the other 
Peristaltic sounds were present There was 
no tenderness on rectal examination but a 
smear of dark red blood stained faeces 
(benzidine +++) was seen on the examin 
ing finger The Hess capillary fragility test 
was negative and bleeding and clotting 
limes were normal A tentatne diagnosis 
of perforation of Meckel s diverticulum was 
made and operation arranged 
At operation performed by Mr F } 
Jauch the pentoneal cavity was found to 
contain a large quantity of dark red blood 
Flecks of fibrin were adherent to the lower 
ileum and a small Meckel diverticulum 
measuring 3 by 1 cm was found arising 
from the antimesentenc border of the ileum 
about 18 in (46 cm) from the ileo caecal valve The 
diverticulum was adherent to the antimesentenc wall of 
the intestine for the whole of its length except for the tip 
and was covered with flecks of fibrin At its base there was 
a small punched out lenticular perforation measuring i in 
(06 cm) in diameter The ileum distal to the lesion was 
slightly distended and the coat was bluish in colour The 
appendix was normal No other lesion was detected in the 
abdomen The diverticulum was then excised together with 
a diamond shaped cuff of intestinal wall surrounding it 
Free dark red blood was present m the intestinal lumen 
The gap was sutured transversely the excess blood mopped 
away from the peritoneal cavity and the abdominal wall 
closed in layers without drainage 

The patient made a satisfactory recovery from the opera 
tion being allowed up on November 16 A barium meat 
examination earned out oi\^ December 1 showed no abnor 
mality and no delay in the passage of the meal through the 
small intestine \VTien last seen on January 6^ 1949 the 
patient was in good health eating well and ready to go 
back to school 

Pathological Report — Section shows typical gastric mucosa 
with numerous well defined oxyntic cells At the base of 
the diverticulum encroaching on both ileal and gastnc 
mucosa there is a subacute type of peptic ulcer which 
has perforated 

Comment 

This case is typical m many ways It falls into the 
usual age group 85% of the cases reviewed by Johnston 
and Renner (1934) were under 16 The perforation was 
preceded by haemorrhage — this is a common occurrence 
70 to 80% ofesuch perforated ulcers having been asso 
ciated with haemorrhage The blood passed per rectum 
was said to be unmixed with mucus and this was con 
firmed by rectal examination Schuliinger and Stout 
(1934) stress this point m the differential diagnosis from 
intussusception The ulcer found at operation was mar 
ginal — this IS the usual site of ulcer associated with 
Meckel s diverticulum — and there was an early attempt 
at walhng off the process, a point stressed by 
and Singer (1932) 




20 Jan 6, 1951 


MTDICAI MlMOkNNDA 


BtrTtni 
MrT»irAi /o' 


However, in ccriiin ispccls ihc ense dillers lioni the 
typical picture Thus, it occurred in i j-irl of the t i e-. 
recorded only 10 to 15% ln\e occurred in fennh 
There was an mimcdnte preccdini, hislorj of ihdnnun I 
pain of tliree days durilion thoUi h this oee • 
sionally occur, it is not common The iculc eohul ^ p un 
complained of on the night before admission w is proo 
ably due to haemorrhige into the bowel ssilh distensior 
of the ileum Gn\ stressed th it there is i m dde 
change from relative well being to an acute illness m iiu 
acute lesion of Mechel s diverticulum In mv ease then 
was no sudden change and it is diflieiilt to st ite whe i 
the perforation occurred 

My thanks arc due 10 Mr r J Jnuch for pcmmsmti to p ibli 
this case and for helpful criticism and ndvic In Mr Jolir llui 
and to Dr R B T Baldwin for llic patholoj isal report 

Donsld M Hancock Mil f h II 

Rrn arsci s 

Johnston L B and Renner G (1934) Airri Ginfc O' t 
59 198 

Schullinger R N and Stout A P (1934) Irch Si/r„ Chi n o 
28 44Q 

Vaughan R T and Singer 11 A (1932) /Inn Ci,r„ 9f, at'l 


Reversible Papilloeclema in 
Pernicious Anaemia 

It IS recognized that anacmi i m i\ be a factor in the 
causation of papilloedcm i >ct reports of its occurrence 
in Addisonian pernicious anaemia ire extremely rare 


Casp RrpoiiT 

A ships boatswain aged Ig was adinillcd to hospital on 
February 1, 1949 with severe pernicious antcmia of one 
months duration In July 1946 he first bccantc ill but 
was inadequately treated His vision had been blurred for 
three weeks and three days before admission he noticed 
swelling of the ankles 

On admission he was gravely ill grossly anaemic and 
slightly juindiecd There was slicht pitting oedema over 
the sacrum Enlargement of the liver spleen or Ivmpli 
nodes was not observed The nutritional state was good 
and no source of blood loss was discovered The blood 
pressure was 120/50 There was no abnormality of the 
heart lungs abdominal organs or nervous system The 
urine contained an excess of urobilinogen but no bile salts 
or pigments and no albumin 

A blood count on Febniary 2 was red cells 1 030000 
per emm haemoglobin 49 g per 100 ml MCI! 
37 7 ry, white cells 3 000 per c mm Films showed macro 
cytosis, poikilocytosis polychrom isia reticulocytes 0 2" 
and no malaria parasites 

Anahaemin produced a dramatic clinical and Incmato 
logical response with a reticulocyte crisis of 29 2"', nine 
days after the beginning of treatment On March 19 his 
blood count was red cells 4 880 000 per c mm haemo 
globin 14 g per 100 ml— a gam of 3,850 000 red cells and 
91 g of haemoglobin in 45 days On February 27 a 

15 seenL^. mtnutes 10 seconds and bleeding time 2 minutes 
twelfth nr^' dis5ppearcd by the 

mai after the first week and the Hess test for canillarv 
hoTpUar He' lTT''h^ throughout hts stay ,n 

m England “ repatrnUon 

Ophthalmic Report 

mmts'‘airu^"”r contracted, ocular move 

•r, s” ns ,= 


Ihluinl pvpillorthma v iv more marked on itr n^ht thr 
It th left venmiv cnioricmcnt and miiliipl t-tirtl 
t i mcirihii's were ot'crvrd Ihc at cries i"cm d ta fr 
n iriii I In loll fiinili liacm'ir/ln?*v ovefbp,-cJ Ite dti 
u II md more p'lipherally miihiple flirrc-shtp' 

I I tot li 11 c in ihc nervr 111 re layer were sewlietcd i- th 
mv I itid temporil airav A di-cp oval shap'd ha — 

1 r wiih (Ictrlv defined cdie was seen one dive dijr"" 

Ml p ' I'ly from lli' rlihl opiK disk An lavtr i 

■n I *1 I d h icmofth igc projcsied anteriorly frm I 
1 ni till of the left miciila and ore d ik dJr " 

V 'I V 1 cirtular Incmorthiyc wav sc-a in l! e d 

iiirin Ihc next month the rapilloevictin rrtiJi. 3 l'j r’- 
m' ' Un MulIi I VI ml icniiy vv-m rithl 6 i|' w h 

I) 1 re at le lo f ,'6 left f M 2 not inprp ed w ^ 

In It' tnemntthares were b'mr ahotb'd pa f ‘ 

mIl mi 111' sucllin, of the neve headv had >' — * 

t , ' 

' In h IS he pvlinit lompi iired of bhiFcJ vi 

i^t e c I viminjlion revl thy reveal'd a f "i 
1111 I cr > 'aye Ihpilloi.d'm3 had siibviJcd 3'J tf 

1 t p Ir 

• ri.h 3| viiiat aciiilv was riphl 6<12 ca-'c"-'^ 

t 1 II fi 6 2 not cotrcvlable by I'Ov" Seat! : 

iiir 111 ih r'v oniinalh seen had b-cn alvoibds ' 
ih'ir p'viii itcs were vhvcovcrcti vuih dill ciiltv If 
01 vtt I 1 . I I'f iiu,iihr Inrnorrhapc was Ivcing aS e' 

I o' V , il’ - ident and Ihc pillor of ll c duks was r" 
r o K II I c 1 ll ' nrhl side than on the left 

CoMvtrvr 

I ’ t 1 inopeneus of papilloedema as of most pat!''’ 
loi 1 I pts of O'dc 113 IS obscure Watkins t! c' 
(I'hi.icpo ltd three cases of ihrombocvlopenic putp-T 
md I ci'e of macmi i clue to bleeding gastric u'et ta 
ill oi winch p ipiDocdcm I vsas notcvl In tlisctissm? th 
intcb mism tiiw postiil tied a local reaction of the lisst-ss 
of the optic nerves to anoxaemia A general oedema c 
the brim due lo the stmt niecbanivm is also mcntioh'd 
IS I possible fictor Fbev did not enlarge on this, 
but presimnblv mcrcised capillary permeability due tP 
oxvgcn lack is rvsponsiblc for the abnormal accumu'a 
lion of extr icclluhr niiid It is nol clear why this pio 
cess should ilfcct one optic nerve more Ihan the oth' 
(in their fourth c isc the left showed clev ition of " ip 
5 diopires the rmlil only 1) 

Simpson (19 IS) reported three cases of emphysema 
vsith papilloedema lie allribiilcd the latter to a rise p' 
ccrcbrospin ll fluid pressure from cerebral sasodilatalion 
due to oxvgcn lack and cirbon dioxide accumulation 
in the arterial blood it is possible lint such a mechamsm 
max operate in maemn However these theories impl) 
a threshold level of inoxacmia and cerebrospinal flu™ 
pressure beyond which one vxovild expect papilloedema 
lo occur Yet C S r pressure m ly be high and min' 
cases of severe aincmn miy bt seen wathout piP'" 
oedema being observed riirlhcrmore the swelling nia' 
be much more prominent on one side Ihan on the other 
It would seem therefore that there must be some local 
factor the nature of which is not apparent 

This paper is subniillcd by permission of Mr A C Tume' 
one FRCSLd Chief Medical Ofiiccr Anglo Iranian on 
Company 

H A Rrm, MB M RCPEd 

W Harris, M RCS, DOMS 
Anglo Irnninn Oil Compnn> 

RnrcRLNcrs 

Simnson T (1918) Dnihh ^fc(^lcal JourtwJ 2 
Watkins C 11 Wnpener II P and Drown R NV (194!) 

J Ophthal 24 1374 



Jan 6, 1951 


REVIEWS 


Bmtoh 

MrorcAi Journal 


21 


Reviews 


DEVELOPMENT OF VISUAL RESPONSES 

Kwion Us De\e!opmenl in Infant and Child B} 
Arnold Gesel! M D F L llg M D and G E 
Bullis Assisted by V llg O D and G N Getman 
O 0 (Pp 329 72 figures £2 2s ) London Hamisfi 
Hamilton 1950 

^This book IS unique m the literature and therefore must 
excite interest Its genesis lies in the Yale Clinic of 
Child Development, which since 1911 has been con 
cerned with the development of earlv human behaviour 
Sy an elaborate series of carefully controlled observa 
tions — much of it m photocine records through one way 
vision screens which leave the child and his attendants 
(when present) unembarrassed—the behaviour of the 
child and his reactions to various visual stimuli have 
been recorded and charted from birth at periodic inter 
vals until school age The study has even included the 
foetal infant — the prematurely born infant — from the 
age of 28 weeks after conception The research includes 
an astonishing number of observations relating not only 
to visual responses but to the whole system of tonic and 
kinetic reflexes concerned in postural activities, m which 
the eyes are important agents The study is a fascina 
ting one for the physiologist the paediatrician, the 
psychologist and the ophthalmologist The authors 
conclude that even in his ocular equipment the infant 
or child IS not a miniature adult but is qualitatively a 
different organism constantly changing and they hope 
that if the techniques described are further elabor 
ated, an appraisal and supervision of the efficiency and 
development of the visual (and other) functions should 
be possible from the earliest stages of life 
The book is interesting to read but to appreciate 
it the reader must understand the American language 
Moreover, he must understand that much of the exuber 
ance — whereby the eye is described as the jewel of 
organic evolution and Tarsitts as leaping around with 
suprasonic speed — is truly Amencan in its delightful 
enthusiasm 

Shew art Duke Elder 


RHEUMATIC DISEASES 

Manual of Rheutnolic Diseases By W p Holbrook 
M D and D F Hill M D (Pp 182 illustrated 
S4 25 ) Chicago The Yearbook Publishers Inc 1950 
This bool is dedicdted to the genera! practitioner and 
jusufies the intentions of its authors They do not 
attempt to present a documented scientific treatise or to 
cover all aspects of the subject but to provide a pracli 
cal guide to diagnosis and treatment especiallv in home 
practice They give a timely warning against waiting 
for miracle drugs and cures while neglecting the simple 
methods directed to preventing the development of 
crippling and deformitv and raising resistance by atten 
tion to the general health Thev describe a basic routine 
bne of treatment which will have a psychological effect 
improve the general health and serve as a basis for such 
other methods as may be desirable The authors hold 
that the most valuable physiotherapy is training the 
patients own muscles through carefully directed exer- 
cises thus maintaining muscle tone and range of joint 
movement and helping the circulation They warn 
against excessive use of heat treatments for while 


comforting at the time they tend to keep the disease 
active and do more harm than good in the long run 
Transfusion is often helpful, but vaccines and manv 
other procedures which have been used in the past are 
condemned as mamlv worthless Gold treatment has 
been found beneficial m a large proportion of cases but 
demands careful supervision signs of toxic effect being 
sought and frequent blood exammations made Clear 
instructions for its use are given A valuable feature 
of the book IS the attention given to prevention of 
deformity, especially in_ home treatment Tables of 
appropriate exercises are included, and the authors 
emphasize the importance of rest and avoidance of 
any exercise entailing over use of inflamed or painful 
joints They recognize the importance of trauma 
postural and occupational strain, and general wear and 
tear in the aetiology of osteoarthritis Excellent illus 
trations guide the reader m the use and application of 
splints supports, crutches and the like 
The authors discuss the most recent developments 
clearly but briefly Cortisone and A C T H , the adreno 
corticotropic hormone, are fully described from their 
own practical experience This is a book which the 
general practitioner will find most helpful and which 
the specialist max read with pleasure and profit 

C W Buckley 


MEDICINE IN BULK 

The Practice of Medicine By I C Meakins CBE, 
MD LED DSc Fdlh edmon (Pp 1,558 £4 15s) 
London Henry Kimpton 1950 , 

Gravimetncally considered, this is probably the 
weightiest textbook of medicine yet published in 
one volume, and of its 1 500 pages over 1,000 come 
from the pen of Professor Jonathan Meakms himself 
It IS a monument to his erudiUon, to the range of his 
knowledge and to his industry Yet the reviewer can 
not do otherwise than ask himself to whom this huge 
xolume IS addressed Is it intended as a companion 
to the student s medical studies or is it meant as a work 
of reference for the practitioner t It is too long too 
detailed and too much concerned with uncommon 
diseases for the first , for the opposite reasons it 
cannot play the second role Perhaps its handsome 
formal and its wealth of illustrations may beguile the 
chmeal tyro into expending £4 15s on its purchase, 
but It IS certain that no hard driven student id his final 
year would make it the handbook for his qualifying 
examination For all this its success is prov^ by the 
demand for five editions in four years 
These observations are engendered by the increasing 
bulk of all the current textbooks of medicine which 
reaches a critical level with the present work There is 
need for an author who will write for students , who 
will limit himself to essentials and principles, seeking 
what he may omit rather than what he may include 
and who will avoid the meretricious lure of encyclo 
paedtsm No textbook can take the place of the great 
systems of medicine and those who require information 
on rare diseases will always need to consult original 
papers and monographs ' 4 

The individual sections in this book are excellent Per 
haps those on the respiratory and cardiovascular systems 
by Professor Meakins and that on the nervous systems 
bv the late Dr Peterson, deserve particular mention 
The introductory chapter entitled An Introduction to 
the Practice of Medicine reveals the broad view and 



22 Jan 6, 1951 


REVIEWS 


Bwrm 

htCDICAL JovrsxL 


mature wisdom which mark the approach throughout 
the book It IS perhaps inevitable that the space dexoted 
to some diseases should seem excessive and to others 
inadequate thus three pages arc occupied by the section 
on acute dilTuse lupus erythematosus three quarters of 
a page by the description of Bouchet’s disease while 
the common ind important complaint glandular fever 
IS allotted less than one page Although it approaches 
the limits of portabihtj, this book has many excellences 
not the least of these arc its numerous illustrations and 

Its fine printing _ _ _ 

R BoDLra Scott 

THE ELDERLY PROSTATE 

Leitfaden fur ProstatILer B> Professor J Minder 
M D (Pp 68 7 diagrams M 4 80 ) Stuttgart Georg 
Thicnie 19‘>0 

Most British doctors would probabl> agree that the less 
a patient knows about his complaint the better It is 
just because of our knowledge that we doctors as a 
class are sometimes so troublesome to those to whom 
xxe appeal for advice on our own poor bodies But 
here is a book which deliberately sets out to tell cxcry 
man xxhat may happen to his prostate Anything more 
likely to make him a prey of the quack it is diBicult to 
imagine 

Yet for those for whom it is not intended, young 
doctors starting m practice the book would be simply 
invaluable The author gives a short and clear account 
of the anatomy of the prostate, of the mechanism of its 
enlargement and of the way in which this may cause 
trouble He draws a useful distinction between the 
troubles which age invariably brings and actual pro 
static disease, and carefully explains the means by which 
this can be recognized With clarity and precision he 
describes the pathological changes in the bladder which 
gradually develop the means by which to some extent 
they may be avoided, and the later effects of bad 
pressure on the ureters and kidneys 
There is an admirable chapter on instrumentation and 
especially on the art of passing a catheter Whether a 
patient could be expected to take such precautions is 
questionable but there is no doubt that a doctor should, 
and many a doctor would be grateful for the hints given 
here The author gives a full account of medical methods 
of maintaining asepsis in the bladder and of combating 
sepsis should it arise, with the most modern methods of 
drug therapy Operative methods arc naturally only 
referred to briefly but every surgeon will agree with the 
remark that whatever new methods may be introduced. 
The best method is that in which the surgeon is most 
skilled and with which he has obtained the best results ” 
This little book is written in very simple German and 
with a clanty that is rare It is full of really useful 
hints and will amply repay perusal 

Henry Souttar 

CHILDREN IN COURT 

ne Child and the Magistrate By J A F Watson 

(Pp 367 12s 6d ) London Jonathan Cape 19J0 

^though Mr Watson is not a doctor his book can 
be safely recommended to any medical man who is 
chnically minded This second edition of his well known 
book, largely rewritten and brought up to date, must be 
studied as a textbook by every magistrate of a juvenile 
court but It IS written in such a way that anyone who 
has to do with children can thoroughly enjoy it from 
beginning to end Those of us who do not exclude 


psychological cases from our out patient clinics will 
recognize on every page the children with whom we 
arc concerned and it is very important for us to he 
able to see these same children through the eye the 
human and kindly eye, of this magistrate 
If the bool gives one qualms at all, it is by making 
one realize what a great deal depends, in the manage 
ment of the delinquent who has arrived at the stage of 
court proceedings on the clinical sense and the human 
understanding of the magistrates and there cannot be 
many in whom arc combined (as they are in Mr Watson 
and his colleague Mr Basil Hennques) a love of children 
With a knowledge of the lavy and of court procedure 
Sentimentality will not do The complexities of the 
Education Act, 1944, the Children Act of 1948 the 
Criminal Justice Act of 1948, and the Justices of the 
Peace Act of 1949 have to be known to the magistrate 
IS anatomy and physiology have to be known to the 
doctor Moreover magistrates need to keep in mind 
that it IS the public interest which as a court of 
justice, must always be their paramount consideration ” 

1 think that general practitioners as well as psychiatnsts 
should Jnovv what to expect of the juvenile court and 
there can be no better way of getting this knowledge 
than throuch the enjoyment of this book Incidentally, 
there are plenty of amusing tit bits to help the reader 
along 

There is one thing which will come as new to many 
readers There is a gap in management left by the 
serious attempt which is being made to eliminate cor , 
poral punishment This gap is to be filled by attendance 
centres provision for which is laid down in the Criminal 
Justice Act of 194S However only one exists as yet 
Mr Watson has great hopes from this new provision 
but one feels that their success will depend not only on 
the way they arc run but on their being used by the 
magistrates for the right kind of case— that is to say, 
for the child who is able to make list of a limited 
corrective 

D W WiNsicorr 
ROOKS RECnVED 

Rnlra Is not precluded by notice here of books recently ttcehed 

Jealousy lu Children Bjl E Zimsn M D (Pp 236 12i 6d ) 
London Victor Golinnci, I9J0 

Ttrst Aid to the Injured Authorized Textbook of the 
St John Ambulnnco Auocintion 40th ed (Pp 2S4 3s ) 
London The St John Ambulonce Assoastion 1930 

What IS Hypnosis i" By A Salter (Pp 94 8i 6d) London 
Athenaeum Pitas 1930 

Text book of 'Orthopaedic Medicine Treatment by Marti 
pulation and Deep Massage By J Cynax M D B Ch 
Voi 2 (Pp 335 I8s 6d) London Cnsscll 1930 

Practical Gynecology By VV J Retch M D T A C S 
FJ C S and M J Nechtow M D (Pp 449 SOs ) London 
J B Lipplncott 1930 

Surgery of the Shoulder By A F DePalma M D (Pp 438 
I40s ) London J B Llppmcott 1950 

Surgery of Cataract By D B Kirby AM M D LL D 
(Pp 695 240s) London J B Llppmcott 1950 

t 

A Compantott to Manuals oj Vraettcat Anatomy By 

C B Jamieson MD 7lh cd (Pp 736 IBs) London 
Geoffrey Cumbcrlegc 1950 

Practical Periodontia By H M Robb DDS B Sc (Pp 117 
21s) London Geoffrey CiimbcrJcfic 1950 




Jan 6, 1951 


PROGNOSIS OF FOETAL ASPHYXIA 


Bwnsn 

Medical Joukkal 


23 


BRITISH MEDICAL JOURNAL 

LONDON 

SATURDAY JANUARY 6 1951 


PROGNOSIS OF FOETAL ASPHYXU 
Doub'ts about the ultimate prognosis of severely 
asphyxiated infants at birth constantly assail those 
who are responsible for their resuscitation Methods 
of obtaimng information lack precision The usual 
and less satisfactory one has been to correlate the 
clmical findings m a group of children which is 
usually speciallyi selected with the birth history 
Schreiber* - inquired mto the birth history of 900 
patients seen by hmi because of defects such as 
cerebral palsy and mental deficiency and found a 
history of apnoea at birth in 70% Faber’ mvesti- 
gated 99 children with mental deficiency spasticity 
or convulsions — m all of whom cerebral atrophy was 
demonstrated — and discovered there had been pro 
longed apnoea or cyanosis at birth in 22 He thought 
that mtrous oxide anaesthesia when given to the 
mother with less than 15% oxygen earned with it a 
particularly grave risk of asphyxia to the foetus 
Belnap and his colleagues * examining 419 defective 
children aged 8 months to 14 years ascribed 52% 
to birth injury and anoxia Rosenfeld and Bradley’ 
studied 673 children admitted to a psychiatnc hos 
pital for behaviour disorders m order to determine 
the effect of asphyxia m infancy on subsequent 
behatiour There were 28 children with a history 
of difficult resuscitation at birth and 126 who had 
had severe whoopmg cough The authors found that 
the children with a history of asphyxia showed a 
charactenstic syndrome of unpredictable vanability 
in mood hypermobihty impulsiveness lack of atten 
tion %ar}'ing inability to recall matenal previously 
learned and conspicuous difficulty with anthmetic 
A syndrome consisting of at least five of these six 
traits occurred more than eight times as frequentiv 
as in the control group 

Preston* reviewed the prenatal and natal history 
of a group of children some of whom vvere chosen 
for studv because of difficulty at birth This group 

* 3 Amer mrj Att I93S 111 1263 

Prdijl 19W 16 297 
•ibid I9<0 J7 326 
•Ar,rr 3 Db Child 1947 4 I 

* r dlltrlcs 1948 I, 74 
•/ Frdln! 1945 16 353 

’ Df>f!cpmenta! DLi^nosl* 1947 New York p 215 
*J Fedut 24 148 

* Aner J Dls ChUd 1950 79 931 
Arier J Obstet Cyrfc 1943 45 183 
Proe Mayo Clin 19^ 25 11 

1 Pediatrics 1950 6 229 

/ Obsiet 1941 42,686 

^^Arch Dls Childh 1950 25 351 
Ar-et J Obstet Cyi-ec^ 1931 21 537 


in which anoxia had occurred m 132 cases was 
therefore a selected one Those who had had lesser 
degrees of asphyxia were hyperactive and hyperexcit 
able those in whom the asphyxia had been more 
severe were apathetic and readily lost emotional 
control Convulsions occurred m 28% of all these 
patients The intelligence quotient was withm nor- 
mal limits m 74% The children tended to lack 
concentration to be difficult to disciphne to play 
badly with others and to be 'slow to learn from 
experience Gesell and Amatruda" earned out a 
different form of investigation In the course of 
their developmental exammations they picked out a 
group of infants with shght abnormalities m the 
pattern of movement, and with clumsiness and 
mcoordmation m finer manipulation They were apt 
to have hyperactive reflexes an exaggerated re- 
sponse to noise early speech difficulties and per- 
sonality deviations All recovered completely without 
sequelae They asenbed this to mimmal buth mjury 
arguing quite nghtly that the history of normal 
delivery by no means excludes the possibility of birth 
injury and asphyxia 

A much more satisfactory method of observation 
IS a longitudmal study from bnth onwards of chil 
dren who were known to have suffered asphyxia at 
birth Darke’ watched the development of 19 chil 
dren who had severe asphyxia at birth and compared 
their IQ with that of siblings or parents Theu: 
mean I Q was 88 and that of the controls was 100 
Two of the 19 children had a higher I Q than the 
controls Stevenson and Stuart’ kept under observa 
tion 226 children who were in a poor physical con 
dition at birth as a Tesult of asphyxia prolonged 
labour prematurity or maternal toxaemia They 
found a highly sigmficant relationship between this 
poor physical condition and childhood maladjust 
-nent In ammal expenments Wmdle and Becker” 
submitted pregnant gumea pigs to the effect of 
asphyxia The offspnng showed not only vanous 
motor disorders but such deviations from normal 
as feeding difficulties and unusual quiescence histo 
logical changes m the brain were demonstrated m 
65% of the ammals at necropsy Different results 
were reported by Keith and Norval ” who followed 
216 children bom after prolonged labour One hun 
dred and eleven had asphyxia hvida or pallida or 
delayed respiration for more than a minute There 
were more deaths among the asphyxiated mfants m 
the newborn penod than among the controls but 
those who survived developed normally over a four- 
year period Even severe asphyxia with delay of 
several minutes m the onset of respiration did not 
seem to have any effect on the survivors The 
same authors desenbed then results m more detail 



24 Jan 6, 1951 


PROGNOSIS or FOETAL ASPHYXIA 


Bumni 

MeotCAL Jovanal 


m another paper *" Twenty four out of 25 full term 
babies who begin breathing after a delay of 1-5 
minutes 15 out of 16 who began after 6-10 minutes 
and all five who began after 11-15 minutes were 
normal at the age of 1 year and remained so Simt 
larly, McPhail and Hill \sho tested the intclli 
genee and behaviour of 34 children of school age 
who had been apnocic at birth, found no ibnor- 
mahties among them 

Finally an informative report has just appeared 
from Belfast Where Campbell Chccscman and Kil- 
patrick'* examined the records of the Royal Miter 
mty Hospital m that city for the years 1938-41 and 
selected for study all the infants who had been born 
m a condition of asphyxia pallida or asphyxia lividi 
lasting for a stated period of over two minutes In 
the end they were able to trace 61 out of 89 " asphyxi 
ated” infants and to compare them with i control 
group of 134 infants bom at the same time The 
examination of the children was so arranged that the 
clinicians did not know from which group a child 
came The authors found no significant difTcrcnccs 
in the average physical measurements of the two 
groups of children in haemoglobin levels or in intelli- 
gence (assessed from Raven s matrices) They con 
elude that the results of tlicir investigation do not sup 
port the hypothesis that asphyxia neonatorum is a 
common cause of later physical or mental retardation 
There are great difficulties in the interpretation of 
these reports It seems clear that those who are con 
suited about defective children arc apt to obtain a 
too pessimistic view of the outcome of foetal 
asphyxia There can be little doubt that asphyxia 
can and docs cause spasticity convulsions and 
mental deficiency but it is not clear how often 
It does so and it is still less clear whether it leads 
to behaviour disorders A mentally or physically 
defective child is more likely to develop psychologi- 
cal disorders than other children and any study 
designed to determine the relation of asphyxia at 
birth to subsequent behaviour disorders should ex 
-■ elude such defective children A special difficulty 
IS the absence of a yardstick by which to measure 
behaviour disorders Behaviour which some would 
consider abnormal others with greater knowledge 
of normal child psychology would Consider normal 
A child s behaviour depends largely on his inherited 
character and on environment in particular the 
parental attitudes and management and this might 
be related to the cncumstances of his birth Elderly 
pnmiparae are more likely to have obstetrical diffi 
culties than others and the emotional background 
of an only child of elderly parents particularly if 
there were seveye obstetneal difficulties or other 
I ^ factors which might render another pregnancy 


impossible could well lead to ovcrprotcction and 
behaviour disorders A further possibility is that a 
child may be cyanotic at birth because of cerebral 
agenesis with its widespread cficcts on the nervous 
system so that the subsequent defects need not be 
the result of the asphyxia at all 

Tlic answer to some of these problems can comt 
only from the study of larger senes of cases but 
here again there arc difficulties Tlic higher the stan 
dard of obstetrics the lower is the incidence of foetal 
asphyxia Darke could find only 49 cases of severe 
asphyxia out of 25 261 deliveries and only 19 of 
these could be traced The investigation which must 
be adequately controlled should include a standard 
method of measuring the degree of asphyxia such 
as that of FI igg '* Tlic development of the infani 
should be assessed by Gcsdl s standards and by the 
other accepted methods at later ages The psycho 
logical examination should be undertaken by a physi 
cian or psychologist who is thoroughly conversant 
with normal child psychology and who docs not 
Inow the birth history of the children whom he is 
examining The results of such studies might do 
much to lessen the widespread pessimism about the 
outlook for these children and they would ccrtainlv 
help doctors to give a sounder opinion to tlic parents 

RFGUrATION OF BODY TEMPCRATURI 
The war gave great impetus to research on the rcla 
tion of man to his working environment and mans 
of the observations have added to our store of bio 
logic il knowledge Much attention has been given 
to the effects of changes in the environmental tern 
perature on the body temperature and Glaser' ’ has 
recently reported the results of some of this work 
When lightly clad men were subjected to an environ 
mental temperature of 0° C for 14 hours the rectal 
and skin temperatures decreased The rectal tern 
perature fell steadily to about 1 ° C below the initial 
level As might be expected the reduction in skin 
temperature as measured on the forehead and on 
the hand was much more marked though the course 
of the temperature change and the amount of the fall 
were different in the two skin areas Tlic forehead 
temperature decreased rapidly dunng the first 15 
minutes then more slowly, until after 30 minutes 
It remained fairlv constant at an average of 4° C 
below the original reading The hand temperature 
however did not reach a steady value but fell pro 
grcssively by about 11 C After the 14 hour period 
of cooling the subjects were allowed cither to rest at 
room temperature (17° C) to do alternate periods 
of exercise and rest at room temperature or to rest 
in a warm room (30° C) Again the temperature 




Jan 6, 1951 


REGULATION OF BODY TEMPERATURE 


Brniai 

Medical Joukkal 


25 


pattern vaned between the different regions The 
rectal temperature surprisingly continued to fall for 
about 15 mmutes and then gradually rose over a 
period of one hour when it became stable The level 
at which It became stable however was always below 
the readmg taken before coolmg and m the case of 
those subjects who had rested at room temperature 
was actually below the last reading in the cold On 
the other hand the forehead and the hand tempera- 
tures immediately began to increase rapidly and within 
li hours settled down either distinctly above the first 
observation of the day if the subject sat in a wann 
environment or' regained the pre experunental level 
if the subject remained at room temperature 
In general the results show that the rectal and skin 
temperatures become fanly constant after about IJ 
hours warming At this point it is presumed that a 
balance has been struck between heat production and 
heat loss though the body temperature as measured 
in the rectum was not restored This seems to mdi 
cate that the establishment of thermal balance takes 
precedence over the maintenance of a constant body 
temperature If this is generally true then perhaps 
the statement that man has efficient mechanisms to 
mamtain a constant temperature should be modified 
to read that he has efficient mechanisms for the mam 
tenance of thermal balance It is interesting to note 
that all of Glaser’s subjects felt comfortable within 
30 minutes of leaving the cold— some time before 
heat balance had been achieved — and they often had 
no sensation of cold even with a rectal temperature 
lower than that at which they had shivered or felt 
cold before It is thus apparent that the sensation 
of warmth must be differentiated from the total heat 
content of the body For instance, a person may feel 
warm when the body temperature is falling provided 
that the skin temperature is such as to arouse a sensa- 
tion of warmth in the skin and in reverse a person 
m thermal balance may feel cold because of a low 
skin temperature Glaser therefore concludes that a 
satisfactory state of body temperature depends on 
balance or near balance between heat production and 
heat loss and a range of skin temperature which is 


t 

since there is no evidence that receptors which mitiate 
shivering he in the w all of the rectum The sweating 
that occuned during warming was not related to the 
attamment of any particular rectal temperature 
sometunes it occurred at a lower rectal tempera 
ture than that at which the subject began to shiver 
on the same day 

The unexpected findmg that rectal temperature falls 
imtially during warming may be due to the peripheral 
vasodilatation that occurs immediately on entermg a 
warm environment mcreasing heat loss at the expense 
of deeper tissues Another suggestion made by Glaser 
appears unlikely — that the temperature m the rectum 
may be affected by the temperature or quantity of 
blood returning from the lower hmbs through the 
haemorrhoidal venous plexus to the infenor mesen 
teric vem The only connexions described are 
anastomoses between the vems of the buttock and 
the rectal veins The rest of the blood returning from 
the lower hmbs could perhaps affect the temperature 
of the blood in the rectum indirectly by cooling the 
blood in the iliac arteries Glaser also points out that 
vanous parts of the body may change then" tempera 
ture within comparatively wide limits vvhile the body 
as a whole remains in a state of thermal balance or 
achieves a balance at a new level and he suggests that 
the balance is maintained by the appropnate move 
ment of blood between the periphery and the mtemal 
organs Previous work’ ’ has shown that the reduc 
tion of penpheral blood flow which is a consequence 
of cooling IS accompanied by an increased intra 
abdominal and cerebral blood flow and that the oppo 
site happens as a result of warming It has also been 
suggested that blood may be diverted from the pen 
phery to the lungs and vice versa dunng the redistri 
bution process ' In another paper Glaser’ has demon 
strated that in a cold environment the vital capacity 
of the lungs is decreased as well as the volume of the 
arm and in a hot environment both are increased It 
seems reasonable to suppose that the cooling resulted 
in “movement’ of blood from the hmbs to the 
lungs so reducing the vital capacity while warming 
caused movement in the reverse direction with an 


subjcctivclv comfortable He found no relationship 
between rectal temperature and shivenng or sweating. 
Shivenng did not appear to depend on a fall of the 
rectal or the skin temperatures to any particular 
level It usuallv began J-t hour after cooling had 
commenced and its onset slowed down the fall of 
rectal temperature or even caused a slight nse due no 
doubt to increased metabolism The rectal tempera- 
ture at which shivenng began vaned from subject to 
subject and m anv one mdiv idual from time to time 
As Glaser points ouL a relationship between rectal 
temperature and shivenng appears highly improbable 


increase m the vital capacity Further evidence of 
this redistribution has been given by Grayson * vvho 
has shown as a result of a study of the temperature 
of the intestine exposed by colostomy or ileostomy 
that within certain limits cooling causes an increased 
intestinal blood flow as well as a reduced penpheral 
blood flow and that wa rming has the opposite effect 

Phrtio! Lend 1940 io1 356 
• \ot f la T>d 1950 166 1068 
•MOlIer O Titrh A ch kl’n Med 1905 8 2 547 

g and S eVcL R Z exp Path Thee |907 4 

- fj: E Sammt \^-\QUnaere ^fed 194-1961 




26 Jan 6. 1951 


CHOREA 


Bumsii 

MnWCAL JOCRJUl. 


CnOREA 

It cinnol be Slid that we know much more about chorea 
than did our grandfithcrs It remains i pu7?lc that a 
disease apparcnilj doc to a profound disturbance of the 
central nertous s>stcm should fail to show histological 
changes in the ncrious sislcm and should lease no per 
manent neurologic il defects Nor it the nnlurc of the 
conncMon between chorea ind rheumatism >ct under 
stood A recent stud> from Scandinasia seeks once 
more to shed light on this Lewis Jonsson' sur\c>cd 
all eases of chorea known to ha\c occurred o\cr a 
35-ycar period from 1910 to 19-14 in i countj in the 
south of Sweden Out of 704 choreic patients whose 
fate was partly known there were 467 cases which at 
one time or another showed rheumatic signs— poly 
arthritis cirditis, erythema annulare or nodules In 
22 eases the chorea was deemed secondary to another 
disease such as hemiplegia, cerebral neoplasm, encepha 
Iitis, or Huntingtons familiil chorea There remained 
215 ciscs of crvptogenctic chorea 
Analysis of the 467 cises of rheumatic chorea gase 
similar results to those reported by other authors 
females were more than twice as common as males 
the age of the youngest patient was 3 years and most 
eases came within the 6-14 ycirs age group the onset 
was more often between Nos ember and M ly than at 
I other times of the scar, the seasonal incideiicc following 
a similar trend to that of rheumatic feser in the same 
region In the group of patients with chorea of 
unexplained origin the seasonal incidence and the age 
of those alTccted sscro much the same as in the group 
of rheumatic choreics, and Lewis Jonsson concludes that 
most of these eases arc due to monosymptomatic rheu 
made infection This view is supported by the fact 
that the proportion of those who arc found to develop 
rheumatism rises as the period of observation is 
lengthened Thus Sutton and Dodge- found that, of 
91 cases of initially uncomplicated chorea, heart disease 
was present in 10% after 3 years, in 15% after 6 years, 
and in 40% after 10 years Nevertheless there remains 
a large proportion of patients probably over 50% who 
never develop any other form of rheumatism 
If a patient has chorea with no past or present cvi 
dence of rheumatism, is it possible to tell whether or 
not he will eventually develop rheumatism ? According 
to Kagan and his colleagues^ ■■ the erythrocyte scdimcn 
tation rate enables this to be done, for after observing 
165 patients with chorea they concluded that a normal 
E S R during a first attack indicated that rheumatism 
was not the cause However, this conclusion is at van 
ance with that of Lewis Jonsson, who found a normal 
ESR in nearly half of a series of 150 eases of rheu 
matic chorea The experience of most clinicians is that 
if the ESR is raised m chorea then some other rheu 
matic sign such as carditis, is usually present but that 
in uncomplicated chorea, even it the patient later 
develops rheumatism, the E S R is usually normal Evi 
dently the factor in rheumatic infection which causes 
a raised ESR is not the same as that vvhich gives 


rise to choreic symptoms Chorea is a well recognized 
complication of pregnancy These patients arc older 
thin the average choreic, and the disorder tends to tike 
a severe form, but in other respects it docs not differ 
from ordin irv chorea In particular, rheumatism is 
equally common, and in 7 out of 18 pregnant choreic 
piticnts in I cw 15 Jonsson s scries rheumatic infection 
hid preceded the chorea The pirt played in chorea 
by emotion il disturb incc is another problematic feature 
I his IS present to some dcgrec,in most eases, while in 
a minority the disease seems to have followed directly 
upon some mental trauma This occurred in 59 of the 
215 ciscs of rheum itic chorea in Lewis Jonsson s senes 
As an iltcrnalivc to this authors view that uncompli 
cited chorea is monosymptomatic rheumatism, chorea 
might perhaps be regarded as a psychosomatic symptom 
vvhich rheumatic subjects arc peculiarly liable to develop 
and which can be provoked by a vnnety of stresses— 
cmoiional, metabolic, or infective the commonest infec 
five factor being rheumatic fever itself 
TTie facts known about this disease provide some basis 
for Its treatment Clinical ciidcncc of active rheu 
niatism, such as carditis, will of course mean that the 
patient needs rest in bed in Us absence strict pnv steal 
rest will not necessarily be indicated though hospital 
care, with or without full bed rest, may well have a part 
to play in helping the child to overcome its disorder It 
is dilTicult for the patient s family to maintain that he ilthy 
neglect of the mam symptom vvhich may be an essential 
part of treatment Mild sedation apart drugs have no 
part in treatment while the little use that is now made 
of pvrothcnpy — whether by the use of protein shock 
nirvanol, or the ' hot box — indicates the me/Tcctive 
ness of such methods 


FATAL iNrrsnriNAi onsiRUCmoN 
There has been a steady fall in the mortahtv rate of 
intestinal obstruction treated surgically In one senes 
of eases in which the obstruction was iiiicomplicatcvl by 
strangiil ition or circinoma the mortality was as low as 
1%,' but in another senes in which gangrenous bowel 
was found at operation over half the patients died" 
Ncmir and his colleagues’ have tried to find out vvhy 
the presence of strangulated gut should have such an 
adverse elTcct By surgical means' they induced total 
obstruction in dogs, with strangulation of part of the 
small intestine After the animals had recovered from 
the anaesthesia it was possible to give continuous intra 
venous infusions as they walked about the cage Two 
different types of fiiiid were found to be extruded bv 
the strangulated gut A pink fluid came off the pen 
loncal surface large quantities might collect within the 
peritoneal cavity, and death occurred from oligacmic 
shock When this loss of fluid was counteracted by 
intravenous infusion, death was postponed for only a 
few hours The animals died suddenly soon after the 
first appearance in the blood of another pigment vvhich 
was also found in the black fluid secreted within the 
lumen of the strangulated gut It appeared that as soon 

JElIason E L and Welly R F Ann Stirg 19-17 125 57 

■Schllckc C 1 Uari,en 1 A and Dixon C r Z Amer mrti Ass 
1940 116 1411 

‘Ann Sting 1949 130 857 874 



Jan 6, 1951 


FATAL INTESTINAL OBSTRUCTION 


BRITTST! 

MrOlCAL JoUKNAL 


27 


as this fluid left the gut and was absorbed into the 
general circulation, where it could be identified spectro 
sco^ically, the animal collapsed and died Separate 
experiments showed that the pink fluid from the external 
surface of the gut was non toxic to normal dogs, whereas 
the dark fluid was \ery toxic The authors point out 
that the black pigment is useful only for identifying this 
particular exudate, and they do not assume that the pig 
ment itself is toxic Although cultures were made and 
were positive for a number of organisms, they do not 
discuss the possibility that the factor responsible for 
death might be bacterial in origin It would be interest- 
ing to repeat the experiments in dogs that have been 
given large quantities of penicillin Although the toxic 
factor remains unidentified, its source seems to have 
been established Further support is given — if, indeed 
any is needed — for early surgery but it also behoves the 
surgeon to handle the strangulated gut with care to 
prevent any further dissemination of its poisonous 
contents 


ACTH TREATMENT OF ACUTE RHEUMATISM 
The interest aroused by the successful treatment of rheu 
matoid arthritis with cortisone and pituitary adreno 
corticotropic hormone (ACTH) has perhaps rather 
overshadowed the claim first made bv Hench Kendall, 
Slocumb, and Policy* that cortisone also favourably 
influenced acute rheumatism If some method of treat- 
ment could be found which effectively arrested the course 
of acute rheumatism and rheumatic heart disease it 
would be not only of profound interest in the study of 
the disease but of inestimable value in eliminating an 
unportant cause of death among young people A valu 
able report on the effect of A C T H on rheumatic fever 
and rheumatic carditis has come from Massell and his 
colleagues" in Boston They studied 10 patients aged 
from 7 to 21 who between them showed most of the 
clinical manifestations of rheumatic fever The first 
case reported is perhaps the most impressive This was 
a girl aged 1 1 admitted to hospital about a month after 
the onset of acute polyarthritis She was severely ill, 
with a pericardial friction rub and extensive sub 
cutaneous nodules — in fact she belonged to that group 
of patients who are nearly always left on recovery with 
a severe cardiac lesion She received ACTH for 51 
days in doses diminishing from 36 mg to 2 mg daily 
Fever and joint pain disappeared in 24 hours and the 
pericardial friction in three davs Mitral and aortic 
murmurs could then be heard Improvement however 
continued and at the end of the treatment her heart was 
normal clinicallv, clectrocardiographically and radio 
logicallv In the other cases the response was less 
dramatic Reporting on the results obtained with cor- 
Usone or ACTH in II cases of acute rheumatic fever, 
Hench and his colleagues’ state that it will talc months 
or vears to determine whether these hormones will pre 
vent the initial development or aggravation of rheumatic 
carditis 

It IS important to remember that patients with rheu 
matic fever as ill as the first child can make, though 

V Fmc Vf ls> €!•- IS-S tt TH 

» \r» £>r( 4 V lOSO SU, MI ted 

* A <■* < 's-r Vfri 19S0 tS S4S 


rarely , a complete clinical recovery From these 10 cases 
It IS clear that ACTH will control the fever and the 
arthritis of acute rheumatism in 24-4S hours, but so 
also will salicylates The diflicultv is notorious of assess 
ing the effect of any form of treatment in acute rheu 
matism which in different patients runs such a varving 
course The only patient with chorea treated by Massell 
and his colleagues improved immediately, but choreic 
movements persisted for 30 days Subcutaneous nodules 
were observed in three children under treatment, thev 
remained present for 45 and 50 days in two and were 
still present at the time the report was written in the third 
The sedimentation rate, too remained raised for any 
thing from 6 to 87 days On withdrawal of the drug 
there was a return in some cases of fever and joint pain, 
which cleared up again when an increased dose of the 
drug was given This phenomenon is of course well 
knovvn during salicylate treatment The tendency of 
ACTH to cause retention of fluids sometimes led to 
an exacerbation of congestive heart failure this, how 
ever, could be controlled by diuretics and restricted salt 
intake Side effects of the hormone treatment included 
the development of acne m six cases, roundness of the 
face m six cases, and striae in two 
From these studies it appears that stimulation of the 
adrenal cortex by ACTH can certainly benefit acute 
rheumatism, though of course this does not necessarily 
mean that an endocrine defect is concerned in the aetio 
logy It IS not clear from the report of the Boston ' 
workers whether ACTH arrests the rheumatic pro- 
cess or whether it merely controls some of the clinical 
manifestations of the disease Many consider that the 
latter is all that can be claimed for salicylates While 
the effect of A C T H on acute rheumatism is of very 
great importance m the study of the disease, it may in 
the end prove to be comparable to that of salicvlates 


SMALLPOX EProEMIC 

Eleven cases of smallpox including one death, had 
been reported in the Bnghton area up to January 1 
(6pm) (see page 48) The usual precautions are being 
taken to stop tlie spread of the disease, but cases 
may appear elsewhere, especially among people who 
have been m direct or indirect contact with the RAF 
officer who introduced the infection from Karachi In 
December this man made three tram journeys between 
R-A F stations in Scotland and Brighton Doctors 
throughout Britain should therefore bear in mind the 
possibihtv that smallpox may occur in patients unaware 
of any contact with a suspected case Notable features 
of this epidemic arc the lack of diagnostic signs and 
symptoms in the initial case with consequent late diag 
nosis, and the spread of infection to laundry workers 
bv means of contaminated clothing 


We record with regret the death on December 30 of 
Mr G R Girdlcstone, who had an international repu 
tation as an orthopaedic surgeon and was Nuffield 
Professor of Orthojaaedic Surgery m the University oL- 
Oxford from 1937 to 1940 He was 69 years of '' 



' 28 Jan 6, 1951 


FUNGUS INFECIIONS OF mc SKIN 


^ fJxnnn 
Mcmcxt JounMAi 


REFRESHER COURSE FOR GENERAL PRACTITIONERS 
FUNGUS INFECTIONS OF THE SKIN 

> in 

r RAY RETTLEV, TD, MD, ERCF 

Physician lor Di^casci oj the Skin StulJlcit\ Uoipiliil London 


Most fungus infections of the skin insolvc onlj the 
epidermis nnd Us appcndigts, the hiir ind the mils 
with compintisely little reiction of the underKing 
tissues For this reason they arc not a \crj potent 
cause of serious disability except when comphcitiuns 
arise Their increasing prcsalencc, howeser, gives this 
group of infections import mcc 1 propose to deii with 
them in roughiv their order of frequency in this country 
at the present time 

Tinea Pedis 

This occurs in two very ditferent clinical forms which 
are, however, often associated together cither simiil 
tancously or at different times in the same patient The 
vesicular form nearly always starts in the centre of the 
sole, under the arch of the foot as i group of perhaps 
half a dozen watery vcsjcles of large pin head size which 
after a few days become superficial pustules At this 
stage irritation may be considerable but the thickness 
of the corneous layer is usually suflicient to keep the 
vesicles intact in spite of scratching 
The pustules gradually dry up and as they do so 
take on a brownish colour so that they arc eventually 
shed in the form of thicl brown scales a quarter of an 
inch or so across It is a week or ten days before these 
scales are formed, and by this time fresh vesicles arc 
often forming near by This process may continue for 
some wiccks, eventually appearing on the sides of 
the feet and toes and even on the dorsum of the foot 
Even without treatment however the process eventu- 
ally seems to burn itself out and the attack subsides 
for a time 

The interdigital form develops more insidiously and 
may consist of no more than a maceration of the skin 
between the fourth and fifth toes, which the patient 
attributes to moisture The eruption is usually a little 
more extensive, affecting the under surfaces of the fourth 
and fifth toes and the skin between the third and fourth 
toes as well Thick white sodden scales are formed and, 
with any unaccustomed walking, painful fissures arc 
likely to appear between and under the affected toes 
Once this interdigital form of ringworm starts it seems 
to continue almost indefinitely and probably forms a 
reservoir of infection from which attacks of vesicular 
ringworm on the sole periodically originate 
A generation or so ago this kind of ringworm was 
chiefly to be found in the Tropics and was spread in 
this country in the public schools and sports clubs It 
has now become so widespread that the name athlete s 
foot IS no longer merited Dr Jacqueline Walker 
has recorded that National Service men on entry to the 
Army showed a 3 8% incidence of foot ringworm 
The diagnosis is not always easy and T believe that the 
clinical appearances of both types of the disease may be 
mimicked by other affections For this reason it is most 


dcsiriblc to cvaminc scrapings before treatment iv 
St irttd s(j th It the di ignosis may be assured All too 
often this cviminilion is left until i prclimin iry period 
of tre itniLiit h is f iilcd ind the fungus m ly then be 
very diflieult to find even though it was originally present 
and the cause of tin trouble For this cximination a 
few scales or the roof of a vesicle arc removed from 
the margin of the affected area placed on a microscope 
slide and flooded vviili lO” liquor potas5.ic After 
five or ten minutes the prcpiration is sufficiently softened 
to flitten out under pressure of thecovcrslip and is then 



Skin scales showing fiinrus iinsinincd prcparalion high power 
I roni a case at Ihe Middlesex Ilospilat 


examined unstained with the high power objective In 
an unlrc itcd case fungus is usually cisy to find after 
two or three minutes search (see F igure) if it is not 
found quickly it is better to take fresh scrapings rather 
than to spend a long time over any individual slide 

CompHcatlons 

It is the complications of foot ringworm far more than 
the disease itself which cause incapacity They are 



Jan 6, 1951 


FUNGUS INFECTIONS OF THE SKIN 


BwTisn 

Medicai. Jouxnal 


29 


nearly always due to secondary infection with pyococci 
or to contact dermatitis resulting from the prolonged use 
of antiseptics and fungicides 

Treatment 

In my experience, the old fashioned Whitfield^ oinl 
ment is still as good as anything Now that coco nut 
oil IS agam available the original formula can be used 
R 

Salicylic acid, 15 gr (1 g) 

Benzoic acid, 25 gr (1 65 g ) 

Coco nut ot! 6 drachms (21 ml) 

Soft paraffin to one ounce (30 g ) 

The ointment should be hberally applied twice daily and 
the foot enclosed in a thin cotton sock or a single layer 
of calico held in place by normal socks or stockings 
In recent years a good deal of research has been 
earned out into fungicides and several elegant prepara 
tions are now on the market There can be no doubt 
that most of them are very effective, perhaps more so 
than Whitfields ointment, but most of them are more 
hable to cause contact sensitivity and a severe form of 
dermatitis which may be far worse than the original 
disease 

Three or four weeks treatment is usually sufficient, 
and durmg this period the patient must be schooled to 
the regimen which he should adopt if he is to tavoid 
recurrence Recurrences are of course all too frequent 
In some cases they seem to be definitely related to re 
infection by wall ing bare foot in a club changing room 
or hotel bathroom It is known that the organism may 
remain for months on an infected floor and that it may 
survive the ordinary process of washing with soap and 
warm water Once the patient has shown that he is 
susceptible to this infection it is important that he 
should get into the habit of never putting the bare foot 
to the floor even in his own home Socks should be 
sterilized either m the autoclave or by soaking for twelve 
hours in 3% cresol before they are washed This period 
of sock sterilization should continue for a week or so 
after the skin has returned to normal Bedroom slippers 
in which bare feet are placed should be either thrown 
away or packed with formalin swabs and enclosed m an 
airtight box for three days Shoes which are worn with 
socks need not be dealt with 
Sometimes there is no history of reinfection, and in 
these cases attacks often seem to follow unaccustomed 
exercise in which the feet have perspired more than 
usual There is little doubt that excessive perspiration 
predisposes to infection and it is impossible to say 
whether the organism has been lying dormant in the skm 
during months of quiescence or whether there is, in 
addition, a fresh infection from without 
It IS therefore important for the patient to avoid 
those things which are apt to lead to excessive per 
spiration of the feet He should wear light shoes 
avoiding rubber soles and in summer open sandals are 
helpful Thin cashmere socks are usually best The 
feet should be washed every day with soap and water, 
swabbed with industrial spirit and powdered with zinc 
oxide and starch powder to which 2% of boric acid may 
be added When recurrence takes place the patient 
should be carefully questioned in order to ascertain if 
possible why the relapse occurred A search should 
also be made for ringworm infection elsewhere on the 
skm particularly in the nails 


Tinea Unguium 

It IS my impression that ringworm of the nails has 
become a good deal more common in recent years 
Climcally, the most constant physical sign is separation 
of the distal part of the nail from the nail bed with a 
dirty yellow or orange discoloration The nail usually 
becomes brittle, and may be ridged or furrowed These 
changes are of course produced by the fungus growing 
in the substance of the nail the nail having been origin ' 
ally well formed For this reason the changes of ring 
worm are usually confined to the distal half of the nail 
and the proximal part remains normal This is perhaps 
the most useful differential diagnostic point, since most 
other affections of the nails are true dystrophies and 
affect the nail matrix so that the irregularity of the nail is 
present from its first formation Another useful diag 
nostic point is the fact that ringworm of the nail nearly 
alwavs starts in one finger or toe and others arc affected 
one by one at random True dystrophies often affect 
all the nails simultaneously or, if they do not, are at 
least symmetrical Ringworm of the nail produces no 
inflammatory reaction in the soft tissues around and 
no symptoms other than the ugly appearance and 
awkwardness resulting from brittleness and difcolora 
tion For this reason the patient will usually complain 
of ringworm m a finger nail but an infected toe nail 
may go unheeded, particularly if it is one of the smaller 
toes 

Ringworm of the natls is caused by the same organ 
isms as those which may give rise to ringworm on the 
feet and elsewhere on the skin An infected nail may 
therefore constitute a reservoir of infection from which 
tinea of the foot or groin may repeatedly develop 

Although the diagnosis can often be made with 
reasonable certainty on clinical grounds alone, it is 
essential to nuke sure by finding the fungus before 
embarking on the long and tedious treatment which is 
necessary Clippings of nail and the debris beneath are 
steeped in 20% liquor potassae until macerated and 
examined in the same way as scales The fungus may 
be difficult to find, and repeated careful search may be 
necessary 

Treatment , 

Sir Norman Walker referred to ringworm of the nails 
as a calamity which no decent person would wish on 
his worst enemy Treatment is difficult and exacting 
and to most patients seems at first out of all proportion 
to the severity of the disease It must be pointed out, 
however, and the patient must understand, that with half 
measures the affected nails will never clear up , they will 
remain a source of infection for the rest of the skin 
and, as the years pass, more finger and toe nails are 
likely to be involved The great difficulty in treatment 
arises because the fungus grows m the substance of the 
nail, the solid tissues of which protect the micro 
organism from fungicides X-ray {reatmfent is without 
effect The problem therefore, is to remove the infected 
nail and thus to expose the fungus to attack with anti 
sepfics 

Conservative treatment consists in cutting away the 
separated nail as far as possible with pointed scissors 
The nail plate must then be systematically scraped as 
thin as can be borne the best instrument for the purpose 
is a piece of broken glass of suitable size and the 



30 Jan 6, 1951 


J UNGUS INFLCTJONS OV IJIL SKIN 


nwitsH 

MOtCAl. jOUKSAl 


scraping should occupj at least ten minutes uscry diy 
After the patient Ins scripcd away as much as he cm 
bear, a suitable application is 1 2 000 pcrchloridt of 
mercury in 50^', spirit This treatment needs to be 
continued for two or three months It is i treatment 
which requires a grcit deal of determination and perse- 
verance on the part of the patient It is seldom possible 
to carry it out properly on any toe nail c\ccpt that of 
the big toe and, since it is time consuming, it is not 
likely to be successful if more than one or too nails are 
affected Tor these reasons I adsisc conscrsatisc treat 
menl with iny confidence onl> for an intelligent \dult 
with one or two finger nails affected 

The alternatisc is remos il of the affected nails In 
this waj the bulk of the inaccessible fungus is remosed 
but it must be remembered that tlie organism reni iins 
on the nail bed and will infect the new nail if it is not 
dealt with The affected nails arc therefore asulsed 
under local or general anaesthesia and the nail bed 
lightls curetted to remove debris A drcssing~of tulle 
gras ma> then be applied and need not be changed for 
a feu dajs After four or five dajs the tenderness of 
the nail bed rapidlv diminishes and the area may then 
be dressed with Whitfields ointment twice daily In 
the CISC of toenails, rest in bed will be necessary for 
a few days, but normal shoes can usualls be worn after 
a sscek or so Fingers must be kept covered with a 
finger stall, preferably of leather it is not satisfactorv 
for a rubber glove or finger stall to be worn for long 
periods Treatment with Whitfields ointment should 
continue for two or three months bv which time the 
new nail will be growing up 

Even this drastic treitment with its upset of the 
normal life of the patient, is not alw lys successful and 
It should be explained to the patient at the outset that, 
although this method is far more satisfactory than 
conservative treatment there is nevertheless a substan 
tial risk of recurrence If this occurs the more drastic 
step of excision of the nail matrix may be considered 
On the toes, particularly the small toes this involves 
little disfigurement but many patients do not like the 
idea However, the permanent loss of toe nails con 
stitufes no disability, and excision of the n ul bed is 
probably wise in recurrent tinea of toe nails if finger 
nails are not already affecled Permanent removal of 
finger nails constitutes as much disfigurement as tinea 
and some degree of disability as well For this reason 
£ would advise repeated avulsion of finger nails if 
necessary rather than complete excision 

Tinea Tonsurans 

Had this article been written four or five years ago 
scalp ringworm would have taken first place It became 
very common during the war but as soon as more 
normal conditions were restored and treatment could be 
better organized, the disease was brought under control 
U is now comparatively uncommon The clinical prob 
lem has been epitomized by Darier “ Any multiple 
scaly patches or dry eczema localized to the scalp m 
children impose the need for a meticulous search for 
broken hairs 

This type of ringworm is very seldom seen in adolcs 
cents or adults and affects principally children, espe 
cially boys between the ages of 5 and 10 The 
well outlined scaly patches are not truly bald, since 
the hairs do not fall out by the roots but snap off. 


leivmg the affected area covered with stumps While 
this IS the eh ir ictcrivlic picture, some patients present 
no more th in a scaling patch .ind the hairs do not seem 
to become bniile In nearly ,ill types of scalp ring 
worm the nffccled hairs fluoresce in ultra violet light 
this IS best seen with a mercury vapour lamp screened 
with Woods glass which cuts off most of the visible 
nys When this is shone on an affected scalp in a 
dartened room individual hiirs containing the fungus 
shine conspicuoitslv with a green fluorescence In this 
Way an infected child can be picked out in i few 
moments examination, and even single infected hairs 
can be found at a stage when the disease could not 
be clinic illv diagnosed I or this reason a lamp to pro 
vide Woods light IS essential for the examination of 
contacts, the prevention of epidemics and the detcc 
tion of rehpscs Ihc fluorescence produced by soft 
paraffin should be carcfiillv distinguished it is of a blue 
colour, and of course can be removed by cleaning the 
hair with ether 

Characteristic fluorescence with Woods light is pallio 
(.twmonic In cases of doubt or if W'ood s light is nol 
vvaihbic the diagnosis of ringworm should be con 
lirmcd by examining a hair m the same way as scales 
Ihc fungus appears as a close mosaic of regular 
rounded spores encircling the hair shaft A proportion 
t>f ciscs of scalp ringworm arc due to the organism of 
cat or dog ringworm Unlike ringworm of the human 
type these ciscs seldom occur in epidemics since the 
infection does not rcadilv p iss from one human to 
mother The distinction cm be made with certainty 
only bv culturing the organism 

Trralnirnt 

Hie treatment of rmiworm of the scalp presents a 
problem similar to tint of ringworm of the nails The 
orginism is protected bv the relatively impervious 
m itcri il — in this ease the hair shaft — m which it grovss 
The starch for a fungicide and for a vehicle which 
would penctrite into the bur shift was being activelv 
pursued in this country a vear or two ago Now, how 
ever, the disease has become comparativclv rare, and it 
seems as though these researches arc hkclv to come to a 
standstill Since, up to now no certain vv ly of reaching 
the fungus has been found successful treatment depends 
on the removal of the infected hairs Tliey cannot be 
removed manually, since thev arc brittle and break off 
and the only successful method which has stood the test 
of time IS epilation with r rays W'hcn earned out 
by an experienced operator this procedure is absohitclv 
safe The hair usually f ills from the whole of the scalp 
about a couple of weeks after the t mvs have been given 
and gradually grows again after a further lapse of three 
or four weeks \ rays have no effect on the fungus 
itself and during the period of baldness Whitfield s 
ointment should be rubbed into the whole of the scalp 
twice daily 

This may seem a drastic treatment, but parents should 
be urged to adopt it without delay conservative treat 
ment IS exacting time consuming and most uncertain 
m Its results 

A child with scalp ringworm should so far as possible 
be isolated from onVr children until after x ray epilation 
IS complete Throughout this period he should wear a 
washable linen cap m order to minimize the spread of 
infection The detection of a ease of ringworm imposes 



Jan 6 , 1951 


FUNGUS INFECTIONS OF THE SKIN 


the need of routine examination of his brothers and 
sisters, playmates, and schoolfellows For this purpose 
Woods light IS indispensable 

Tinea Cnins 

This IS usually caused by organisms which may also 
infect the feet or the nails Known as dhobie itch. 
It was formerly chiefly farmliar as a tropical infection 
contracted by wearing clothing which had been infected 
during laundering The eruption appears as a bright 
red Itchy disk on the inner aspect of the thigh two or 
three inches below the crutch The affected area is 
scaly and sometimes there are a few tiny vesicles at the 
margin , very often the margm is a little raised and 
palpable, with a tendency for the patch to clear up 
spontaneously in the centre As the patch enlarges it 
extends to the inguinal region, thigh penneum or 
scrotum In differential diagnosis this form of ringworm 
IS to be distinguished from intertrigo the latter always 
starts exactly in the groin fold and not a few inches 
down on the thigh . Extending from the fold it usually 
affects opposing surfaces symmetrically At the margin 
of a. patch of tatcrtrtgo fofficafat fcstoas ate very oftett 
to be seen tinea of the thigh is never follicular Unless 
the clmical diagnosis is quite certain it is always best 
to remove a scale, preferably from the margin of the 
patch, and examine it microscopically The fungus is 
easy to find 

Treatment 

This form of ringworm responds well to treatment 
Whitfields ointment may be rubbed into the affected 
patch twice daily for a fortnight or three weeks, and 
seldom fads Recurrences are not very unusual and are 
probably most often due to a reservoir of infection on 
the feet or nails In order to avoid reinfection from 
clothing underwear should be boiled during the period 
of treatment 

Pitynasis Versicolor 

It IS difficult to say how common this type of ring 
worm IS , very often it is found on patients who are 
being examined for another purpose, and although some 
patients complain of slight irritation, many people do 
not notice its presence The eruption appears pnnci 
pally on the back and front of the trunk and is made 
up of patches or sheets of a faint fawn or brownish 
colour It IS usually only when the patches are scraped 
that a fine adherent branny scaling becomes evident 
The patches are well outlined, but there is no erythema 
or other alteration of the skin When scales are_ 
examined microscopically fine filaments of fungus can 
be seen together with clusters of spores 

From the absence of any inflammatory change it is 
cleat that this infection is extremely superficial Symp 
toms are negligible and it is not easy to persuade 
patients to use messv ointments over a wide area of the 
body for such a trivial complaint, since there are indeed 
no complications Because of this I usually give a 
lotion consisting of 50% spirit containing 1 2 000 
mercury perchloride to be swabbed over th^ affected 
areas twice daily Underclothes should be boilTd dufing 
the period of treatment In practice the eruption s 
rather resistant to treatment, and shows a strong ten 
dcncy to relapse I suspect this is largely because it is 
so difficult to ensure that treatment is effectively earned 
out 


BRmsa "31 
Medical Jouwial 



LORD BORDER 80 

Lord Herder who is 80 years old on January 7 can look 
back on a life of unrivalled service to the profession and 
\Vit public StiW Wvmg ttit pbysicat encigy and mental 
alertness of a man many years younger than himself he can 
too look forward to giving — and we to receiving — many 
years of active and pertinent counsel in all those various 
aspects of hfe and medicine which have engaged and held 
his unflagging interest As was said of him in the Sunday 
Tunes a year ago TTie societies of which he is either presi 
dent or chairman are mainly those which support the right of 
an individual to decide for himself those matters which con 
cem only himself Some men prominent in public life come 
to assume a public mask When on the public stage they 
play a part which has been carefully studied and rehearsed 
But Lord Horder on public and private occasions has 
always been himself forthngbt and direct in speech that at 
times has the precise sharpness of the etchers tool He 
has been and is an individualist in the best meaning of this 
word It IS surely this added to his brilliant qualities of 
mind and unusual capacity to observe what he sees which 
has made him the supreme clinician of his day It was an 
almost uncanny observation that led him to supply a criti 
cal piece of evidence when he was called in during one of 
the illnesses of Edward VII 

It IS just over forty years ago that Dr Thomas Horder 
(as he then was) published his classical description of sub 
acute bacterial endocarditis He was the first to isolate a 
streptococcus from the blood in this disease and establish 
it as an infective condition This was the fruitful outcome 
of his early awareness of the importance of clinical 
pathology the subject of his first published book in 1910 
In the early years of his consulting practice he did his 
own pathology with the help of what came to be known as 
Holder s box containing test tubes culture lubes blood 
counting apparatus and a blood culture syringe He brought 
clinical pathology to the bedside at a time when too many 
were content to bring only the bedside manner Lord 
Borders clinical exemplar was that great Barts physician 
and teacher to whom he was house physician Samuel Gee 
and part s holds in grateful memory Gee s house physician 
who in the course of time also became a great physician and 
teacher in an institution which for over 800 years has been 
an active witness to the continuity of medical history _ 


The International Hospital Federations Nens Biillelin 
reports some differences from Bntish practice noted in a 
tour of Swedish hospitals Bedpans are never sterilized a 
good dousing in cold water being considered sufficient 
Creeping plants in pots and boxes are often trained up the 
inside walls of wards and hospital rooms the patients like 
It and doctors and nurses see no harm in it 


32 Jan 6, 1951 


MEDICAL NEW YEAR HONOURS 


Dumtii 

Medical Jo< rsal 


MEDICAL NEW YEAR HONOURS 

The mmcs of the follouint members of the mcdicnl profes 
Sion were included in the New Ycir Honours I iM published 
in the London Gazette on Janu ir> 1 

KC VO 

Damel Thomas Davies CVO MD f R C I* rh>Mcnn 
to the kine 

Trancis Hugo Tcall CVO MD IRC I* Honor*ir> 
O/Ticer in clnri.c of Imrnunoihcnp> Depirimenl Uni\er5il> 
College Hospinl London 

K U C (Ci\tt Dixislott) 

Percy Selwvn ScLwvN Clarke CMC C MD FRCP 
Go\crnor and Comnnndcr in Chief of the Scvchcllcs 

Jlon KSr (Cnit Dnhion) 

Tr^ancis Akanu IniAM Hon OUP MR Ch R Member 
of the Executive Council Nigeria 

Knlf^hthood 

koFOwoROiA Adekumc Aravov!! MD Member of the 
Executive Council Nigeria 

Trank M^cearlane Rurmt MD Sc D PhD TRACP, 
FRS Dircclor of Waller and rii?*! Ihll InMitutc Melbourne 
Ausinha Tor services to biological rcseirch 
W'lLLlAM kELSlYfRY COF \f C MDS TDS MRC^ 
LRCP Dean of the Tncuhy of Dental Surgcr> of the Royal 
College of Surgeons of England 
Gordon Morgan Holmes CMG CRT Hon ScD Hon 
DCL MD FRCP FRS Consulting Physician Charmi 
Cross Hospital and National Hospital for Nervous Diseases 
London 

CD (Afthtary Dhtshn) 

Kcnnitth Allvandfr IscLcnv MACKEsrip BM RCh Sur 
eeon Rear Admiral Honorary Physician to the king 
Thovias Young ORF MB Oi B Major Genera! laic 
R A M C Honorary Physician to the king 

CAf G 

Clifford Crato MD MS TRACS Surgeon Superin 
icndent Launceston General Hospital Tasmania 

V 

CVO 

George Proctor Middleton MVO MB Ch R Surgeon 
Apothecary to His Majesty s Household at Balmoral 

CBC (Afilitary DtMSinn) 

VyvYVN Stewart Ewing MB Ch B , D P II Air Conimo 
dore RAT 

CBC (Ci\tl DiMslon) 

James Boyd MD FRCPI DPH Chief Medical OfTiccr 
Ministry of Health and Local Government Northern Ireland 
Lucy Merfditii Bryce MB RS IRACP Honorary 
Director of the Blood Transfusion Service Viciona Australia 
Joseph Stanley Hopwood MB B S Medical Svipcrintcn 
dent Broadmoor Institution 

Peter James knRLCY MD FRCP TTR Director, 
Radiological Department Westminster Hospital Consultant 
Adviser on Mass Radiography Ministry of Health 
Geoffrey Marshml OBE MD FRCP Principal 
Medical Referee to the Civil Service Commission 
kAMiL Mohamed Ariff bin Kadir Mustan LMS Tor 
public services in the Federation of Malava 
Advm Rankine MC mb Ch B Lilcly Colonial Medical 
Service Director of Medical Services Mauriiius 
Vincent Brian Wicglesworth MD FRS Director of 
the Unit of Insect Physiology Agricultural Research Council 

O B C (Military Division) 

cSl rTm Lieutenant 

ma^derRAF*'’ Ch B Acting Wing Com 


OBL (Chil Dhislon) 

JaM! s Tanstonl MD Physician Surjeon and Founder of 
the Hospital Lvangclico Annapolis cm Goya? Esiado dc Goyaz, 
Rra/il 

T HOMAN Ghrav MB Ch R A medical practitioner of 
Napier New 7calind 

Don Sam dc Simon LRCPt^SId Medical Supcnnicn 
dent leprosy Hospital IKndala Ceylon 

John AiiVANiitR jAstis Ch M I RCS A pfomincnl 
pliystCian and surgeon in the Australian Capital Tcrrilory 

Attvandtr Camfro MckiLLoi MR Ch B of Christchurch 
New Zealand for scrvitcs to psychnlry 

WiitiAM Hunt Climokd Paekick MD Regional Medical 
Ofliccr Ministry of Health 

Mohamid At! Rana MRI M R C^S LRCP Tor public 
services in kenya 

Andhtw Jami s SitivNti MD DPH Medical Oniccr of 
Health City of WcMinmsicr 

Sisnatamtiv SurpAMANiAvt, I R C PAS Cd I or medical 
and social services 

At sN RontRT StANifv \icnrRs Ch M Tor services to the 
flying Do-tor Service In Australia 

I ION Jami s W H HAMS MD I or public <cnrcv m B-rmuda 


MBl (MiUtars Dnhlon) 

IfAVtitTON Jav!i s I I VERSON, n M B Cli Major (tcmnotaty) 
R A M C 

WiitiAVf Rovd Jack R\1 RCh Acting Interim Surgeon 
Lacutensnt Commander R N 

Tirenci Richard Jasmn LD LKCPAiSEd Major 
Ceylon Medical Corps 

Trevor Siakseipid Law MR, Ch B Surgeon I leu cnant 


M BS (Chil Dnhhn) 

Arihur Grhiitiis Tarr MB RChir Colonial Medical 
Service Acting Senior Medical Officer Tanganyil^a 

SsMUtt ItRCHsoN I toM) MU U Ch General Medical 
Pracutioncr County Down 

Ar Ni a Grace Gillispie MR Ch B Medical Missionan 
Mary Calvert Holdsworth Memorial Hospital Mvsorc City 
India 

Jolts Jamir Sparks I M S British Vice Consul at Coatza 
coalcos Mcvjco 

I RANcts Hinrv Whitt iitad M R C^ LRCP Chairman 
Wandsworth and Ratiersea War Pensions Committee 


At a pathological meeting of the 1 iverpGol Medical 
Institution on Tluirvchy D cember 14 Dr R C RcwcII 
pathologist to the I ondon Zoo read a paper on The 
Pathology of Captive Wild Animils He siid that the 
size shape and metabolism of cells was limited and con 
trolled by factors imlcpcndcnt of the dimensions and struc 
hire of tilt whole animal Thus a granulosa ccllud tumour 
of the ovary had the simc structure and might show the 
same vinalions in a small monkey as m a woman or as 
in a giLanlic whale However such tumours lotild bt 
found only in inimals witli Graafian folhtics Variation 
m the structure of organs conditioned local v irnlions in 
the results produced by discise Inflimmation of the lung 
of I reptile which has no closed spaces produced i condi 
tion comparible to enteritis tn mammils the lung of a 
bird with its through and through irrangeinent became 
completely solid while the numerous blind ends i>f a 
niammilian lime g'lve rise to the characteristic lobular 
consohdition Differences in metabolism must be re 
sponsible for such things as the high incidence of 
Lacnnccs cirrhosis of the liver in the Arabian camel 
not seen in the closely related Bactrian camel though 
both are iisinlly on the same diet wink in a zoo Skin 
bods in ungulates were due to a coryneb iclenum while 
in Equidae artcriil aneurysms were caused b\ the worm 
Sfrongy/ns \ufgans Some of these pathological condi 
tions might be useful in the selection of suitable expen 
mental animals outside the ringc of those commonly 
employed 



Jan 6, 1951 


REPORTS OF SOCIETIES 


Buttsh 

Medical Journal 


Reports of Societies 


ROYAL SOCIETY OF MEDICINE 
AETIOLOGY OF PNEUMONIA 
The subject of pneumonia was discussed by the Section of 
Epidemiology and State Medicine of the Royal Society of 
Medicme on Friday December 15 1950 

Dr W H Bradley from the chair said that the 
comparative mortality index of pneumonia (all forms) 
taking 1938 as 10 had been 176 in 1911-15 and 
■was 0 5m 1948 There had been some fall even before 
the introduction of the sulphonamides in 1935 Deaths from 
all forms of pneumonia were 26 786 in 1935 and 20 792 m 
1949 Notifications were 46 401 in 1935 and 34 538 in 1949 
Pneumonia remained a very serious problem 

Dr J G ScADDixG pointed out that it was impossible to 
classify pneumonias purely on an aetiological basis Certain 
pneumonias were due primarily to a breakdown of the 
defences of the respiratory tract When this happened 
organisms in the upper respiratory system not normally 
pathogenic might gam access to the alveoli and there cause 
an inflammatory reaction He therefore divided pneumonias 
into two broad groups the acute specific pneumonias and 
the aspiration pneumonias In the former group were 
included pneumonias due to specific bacteni viruses 
nckettsiae fungi plasmodia chemical substances and 
allergy He also included in this group pneumonias associ 
ated with viruses such as those of influenza and measles and 
due to the combined action of viruses and bacteria Aspira 
tion pneumonias were preceded by an upper respiratory tract 
infection or by bronchitis Commonly the illness began 
insidiously and respiratory symptoms were prominent in 
contrast to the typical virus pneumonia in which constitu 
tional symptoms predominated but it was admitted that in 
many cases the clinical differentiation was difficult 

Dr Scadding gave an account of aetiological studies 
earned out by his group at the Postgraduate Medical School 
of London since October 1949 There were 110 cases of 
pneumonia He contrasted the low incidence of pneumo 
coccal pneumonia (26%) in 1949-50 with the much higher 
incidence (68%) at the ^ame hospital jn 1938-9 Most 
pneumococcal pneumonias occurred during the winter 
months but they continued sporadically during the summer 
All 10 staphylococcal pneumonias were seen between 
October and April There were eight cases with cold 
agglutinin titres of 1 256 or above and these were all much 

younger than the average age for the series there were no 
constant clinical features and the cases were distributed 
throughout the year There were a few cases with serological 
evidence of ornithosis or Q fever The influenza B cases 
occurred from January to April 1950 and were associated 
with pneumococcal or staphylococcal pneumonias or with 
those of undetermined aetiology In no fewer than 27 cases 
which had had no chemotherapy before admission no 
aetiological agent could be identified Eighteen were 
scattered lobular or segmental pneumonias and most of the 
patients either had had a preceding upper respiratory 
tract infection or were chronic bronchitic subjects It there 
fore seemed likely that some at least were essentially 
aspiration pneumonias 

Professor C H Stuart Harris considered that the 
majonty of infections of the lung were due to bacteria but 
he stressed the frequent association of pneumonia wilh 
upper respiratory tract infections at all ages He had found 
a fairl> close relationship between the pneumonia death rate 
from season to season and the deaths in the great towns 
recorded as ^ue to influenza With his colleagues he had 
studied cases of pneumonia and other respiratory diseases 
admitted to hospitals in Sheffield between October 1947 
and April 1949 He contrasted two phases within this 
penod The first phase extended from October 1947 to 
December 1948 during which time only two sporadic infec 
lions with influenza A virus were recorded among some 85 


3 *^ 


cases studied Seventy seven of the cases studied had 
had pneumonia and th^re were three deaths During the 
Second phase from January to April 1949 there was an 
epidemic of influenza A In iHTs phase 95 cases were 
studied there were 70 cases of pneumonia with 16 deaths - 
There was some contrast in bacteriology between the two 
phases staphylococcal infections were much commoner in 
the second phase Of nine cases from which influenza A 
virus was recovered at necropsy the lungs were infected 
With staphylococci m six During this phase serological tests 
for influenza A were positive in 27 out of 57 cases of upper 
respiratory tract infection in 11 of 53 cases of non fatal 
pneumonia and even in four out of seven cases of 
heart failure Though some cases of staphylococcal and 
-influenza A infection ran a fulminating course suggest 
ing a symbiotic attack by the two organisms cases of com 
bined infection with pneumococci and influenza A seemed 
no more ill than those infected with pneumococci alone 
Dr B P Marmion discussed serological tests for influenza 
cold agglutinins streptococcus MG Q fever and the psitta 
cosis-omithosis groups Sera were submitted to the Central 
Public Health Laboratory at Colindale from all cases of 
pneumonia admitted to two large hospitals and from various 
cases of respiratory infection elsewhere in the country 
Between June 1949 and May 1950 24% of sera from cases 
clinically diagnosed as influenza or febnle catarrh 
were positive for influenza B 14% of cases of lobar 
pneumonia were positive and 16% of cases of atypical 
pneumonia ’ Twenty^one per cent of~cases diagnosed as 
atypical pneumonia had positive cold agglutinins and 
5 6% were positive for-Q fever The 26 cases serologically 
diagnosed as ornithosis were evenly distributed between the 
different clinical diagnoses suggesting a lack of any well 
defined clinical picture Of these cases less than half had 
any clear evidence of contact with pigeons chickens or 
parrots ^ 

In this senes cases positive to serological tests for omi 
thesis and Q fever were evenly distnbuted throughout the 
year The influenza B cases occurred between January and 
April 1950 Cases with cold agglutinins were seen at all 
■ seasons hut were more frequent between December and 
April positive litres for streptococcus MG occurred only 
m those having significant litres of cold agglutinins _ 

Dr Marmion discussed the significance of the test for cold 
agglutinins This lest was positive \n a high proportion of 
volunteers infected by the American Commission for Acute 
Respiratory Infections with filtered material from primary 
atypical pneumonia It was clear therefore that the 
reaction was associated with a virus infection Eaton has 
brought forward good evidence m favour of his cotton rat 
virus being the infecting igenl responsible but the evidence 
could not yet be regarded as conclusive The position' of 
streptococcus MG was uncertain It was not clear whether 
the organism caused pneumonia itself or whether it was 
symbiotic with a virus in the same manner as m swine 
influenza or whether the streptococcus MG shared an 
antigen with the causative virus 


WHAT IS GENERAL PRACTICE? 

The first regular meeting of the newly formed General 
Practice Section of the Royal Society of Medicine was 
held on December 20 1950 under the chairmanship of 
Dr G F Abercrombie when there was a discussion on 
What IS general practice *> 

Dr G O Barber (Great Dunmow) honorary secretary 
of the Section said that when the Section was bemg formed 
this question was asked again and again so that it seemed 
logical at the first meeting to face it and to define medicine 
as practised b> the family doctor m so far as it differed 
from hospital and specialist practice 

He recalled an incident of 20 years ago He was a young 
doctor and the old practitioner was dying \\Tule he was 
in a little room combined waiting room and dispensary 
behind a partition of wood and frosted glass he heard one 
woman who was waiUng say to another, 1 don t think 



34 Jan 6, 1951 


Rcpoinsoi socintins 


much of )ounp doctor nic> s\> he cxofufori people 
to find otil wlnt n wnuie with them It hid tot^en turn 
mnny yents to rcili/c that tint t,ood Ivdy m-w »i|ht Not 
thtit one should not examine one x patientx and i cep rccottU 
of them hut Mint tnil been home in upon him mi that 
the }ood prittitioncr in hvine voi xnmK amour hit paticnlt 
shjfinp their life in \illiic or toMii loOMtiir them and llieir 
vvorh the 000(1111001 under mIikIi thci hied their piirmiti 
vicei loie aflairi and io on jot xo mtinntc a hnoMleilje 
of them that tonp and dctiiled e\ itninaiioni I'cani' 
supcrnuotii in a mmih''r of c i ci 

Tile Jiinrle and |lie /on 

Tltc pencral practitioner Dr flithet nent on Mai n 
natiiraliii piirminp tin (ivutry and itodyinj, ti |iiluti in 
the jtinplc the ipecntiit ohictiied only the ip'a.iateiti m 
the zoo To put it in another May the iiiuK of the ore 
Mai !n \i\n and of the other in iliro The enenic of 
peneral practice M'i ilic ittidy of nun in hn oauirjl 
ennronment The ipcnaliit Mai handituppcd hy hiiinj 
to taVc n one aided aniMcr to hii qiicitiom Mhereai the 
pcncral practitioner hncM many of the nniMCrt automatic 
ally He hnev. hiv patient i heredity .u mcU hi Im eniiron 
ment and tint Mai often helpful for initan e Mhen 
the streii lyndromc hepan to deiclop One oliened 
rJ/lTerrnJ mrmi'Cri of a hmilf temhnp in hrrai doxrj 
tinder the «mc itten or under dilfercnt itrcaici in the 
lame May 

Ai mtdieme am! lutpcry and the allied »pecultict hectmc 
more complicated and their lechnUpic more and mote a 
mailer for expefti mIio Mere at the lame )oh all the lime 
many helieic<! tint the pencral praclilioncr uai tfoomed to 
the role of an mtclhpcnl iipopoit He t>chcied directly (he 
oppOMte The piticnt could not he divided and If any 
fpecnl aipect of him had to be inveitipated It mu the duty 
of the penetal practitioner to ovence tint invcitipaiion to 
the iiimoii limit of tili undefstandint and to enviite that 
the spcciilly Mm applied to the patient in full InoMltdpc 
of the patient i circtimtlancei The pcneral pracliiioner 
muil not lend Ins pilicnl to lioipiial and fort el all ahoitl 
him until he came hacl. npain 

Rciponiihdity tn pencral practice Mai continuoui and 
somclimci tool the practitioner a conuderable dm incc aM-ay 
from pencral medicine Ocncral practice involved the Ircit 
mcnl not so much of the pomlilc triviality which hid caoicd 
anxiety in the home and pethipv in the ncij hhoiirliood ai 
of the herd panic itself It wai for the pricliltotier to allay 
that anxiety as well ns actually to dninosc and treat the 
case 

nlrlli and Death 

At no time was this more marled linn on the two preai 
occasions of birth and dcith AI a birth there Merc more 
people in the house than the mother ind the child There 
Mere the expectant father and Rnndpircnis ind their treat 
ment could be ns prcil a trial to the icncril practitioner is 
the hinUlint of the confincnicnl itself Derth ipain ssas 
somethmt which Mas the concern of pencral practice there 
wis not only the dyinp patient mIio mis usually the least 
conscious of the concern he aroused hut his family and 
friends The vviy m which the death ssas hmdlccl bv the 
general practitioner might m Ac ill the dilTcrcnce In an 
age which must regretfully be described as irrcluioiii there 
often fell to the gcncril practitioner on such occasions 
something of the function of the priest 

In chronic cases it was often said that nothini could be 
done But general prielicc consisted in doing something 
to make life as bearable as possible for the palicnl and 
to make him live as comfort ibly ns he could with bis dis 
ability On the research side ihcrc were v irioiis mailers 
which might engage the practitioners atlcnlion such is the 
observation of seasonal epidemics not necessarily the serious 
epidemics but the minor cases the transient vertigo nausea 
and vomiung the epidemic myalgia the occurrence at cer 
tain times of a series of cases of acute bickachc or pain 
OB turning the head 


ftimw 

Mroicet rouiMAL 


Dr Barber said in conclution that general practice was 
still and iilways would be jim what the individual general 
pritlilioncr made it It vas not a quciiion of defimiion 
by any medical body bul it was the g cncml pncliUoncr s 
own eonccplinn of service to tin palicnii exemplified by 
the itindard of hn wurl and hn Milhngnen (o accept 
reipofitihihly Ir »ai the whole care of his patient in the 
numial environment and to the mmoit extent 


I rperfi In Divlronment 

Dr J 1) Sinpsr) ( tr anibndgel said that the general 
rractitionT knew I ui little of clabotalc techniques in 
diifiiosli and iteilm'-nl h' ncccpicil them and wed 
them to ailvoc or treat the patient tn relation to his or 
1 cr backtround and it uii of ilm environment that the 
rencral practilloacr ifioutJ hive special knowledge 
Or Simpson give inslaneei in which the qticilion of fit 
ncii for alhleti~i tame N-fore ih' general practitioner 
npcciatly in a iimvcriity Iomti On such occasions he 
mint rely on his Inoivlrdic of the palienl the game itself 
and flit oun immednte /udiimcnt 

Another pruhtem wai fin and faints ” Just as one 

SMattosv did not make a summer so one tramienl loss 
of coi's^iiiitsness did not justify a diagnosis of epilepsy 
In these days of the svorship of scicnlific invesligaiion 
Ptaclitioncfs Mere often asked to have icm carried on! 
An eleclroeneephalogram would la lh^c circumvlanecs in 
easel out o' 10 only confuse the issue and so would the 
aclininistration of phenobarbilone to stop any further fits " 
uhtess the orginat attack tiad been seen by a rtallv relublc 
Witness and there was no question at nil of the diagnosis 
A quick reference to “fils" in a medical students text 
book would soon convipce the palicm that he had epilepsy 
With all 111 concomilani misery How mueh better and 
more courjpeoiii to tell the palienl lhal ii svai a faint 
and to nail without Rising driipi until the next atnefc 
"luch niighi never occur Sometimes of course the dsKtot 
"mild N* wrong and there might even be trageslv but he 
mainl lined that the number of patients saved from the fear 
sif a disease which they Ind not pot would amply justify 
this action 

Kfsearth fn Gentml Practice 
Dr Simpson addcsl n word about research in general 
practice The opporiiimlies for research were twofold 
Tlicrc WIS first the longterm collection of cases of a 
panicutir discise Wien p! inning a definite mveitigalipn 
of this kind the pnctiiionct should seek itatinical adiice 
at the outset and use a speci it forTi for hn notes so that 
they miclit be of real s due Nothu v is more maddening 
lb in to look up a past case and firj lint the notes were 
mcompleic so tint the cue couM not be included in a series 
Ills second opporiumiy for reseirch was in the recojni 
iKm of climval syndromes ssficn these occurred in epidemics 
Tsir esauiptc Ihc spcikcr hid recently had n group of cases 
of gistro cntenlis with suih violent miestinal colic that 
heavy sedation had been nccc's iry He bad Ind IQ such 
ciscs within four sliys Dcscripiion of such outbreaks at 
mcciinjs of the Section Mould he of the greatest saluc 
In toncliision he summarized his views of the special 
responsibilities of Ihc general praclilioncr as follows 
(I) he should he csperl m the cnsironment of hiv patients 
(21 III. should have the courage of hts consictions and not 
be afriut of accepting responsibility sslicn this ssould sasc 
hi\ paliems fear ind niixicty (3) he should bring to the 
ness Scclion of Gcncril Pr ictiee notes of the pattern of 
common diseases so tint general practitioners could learn 
by discussion in the same w ly as their specialist colleagues 

“Only n GP” 

Dr r P Scott (Mnrylebone) declared that general pracU- 
lionciN were the backbone of the medical profession There 
had been a slightly derogatory feeling about people who 
Were in general pricticc — they were only GPs — hut 



Jan^ 6, 1951 


repoiIts of societies 


Bmisn 

Medical Jourkal 


35 


this was unjustified There were certain attnbutes which 
every practitioner who wanted to be successful must possess 
The most important was personality the second a know 
ledge of his work Perhaps the third should be luck and 
the fourth a combination of a warm heart and warm hands 
He quoted Lord Dawson of Penn as having said to him 
The treatment of patients is 50% the treatment of the 
relatives On the question of research in general practice 
he mentioned the achievement of Sir James Mackenzie who 
did all his research work in Birmingham as a general 
practitioner 

Dr C H Bjllington (Haileybury) spol e of the interest 
of general practice at a public school it was the more 
stimulating because it was concerned with health rather 
than with illness Dr Rayner (London) said that general 
practitioners very often did not p-iss on sufficient informa 
tion when their patients went to the hospital or the specialist 
Dr Lawrence Dulake (Reigaie) said that the work of a 
general practitioner depended so much on the neighbour 
hood in which he lived the kind of practice he followed 
and his individual personality that generalization was diffi 
cult Patients often expressed a desire to see a proper 
doctor The general practitioner was a proper doctor 
All the rest were incomplete doctors Doctors had some 
times been divided into two categories — the tut tutters 
and the pooh poohers He specially deprecated the tut 
tutters for they somehow communicated their own real 
anxiety to the patient At least half of the patients coming 
to his surgery suffered from some psychiatric upset Some 
times this was an overlay but very often it was the mam 
trouble 

The Bottle of Medicme 

Dr E T Hughes (West Wales) said that when he looked 
at Sir Luke Fildes s picture The Doctor (the original 
was in the. Tate Gallery) it made him feel very humble 
There was much that they the younger men could learn 
from the old family practitioner He himself succeeded a 
dear old country doctor of 83 and he learned a lesson a 
very few days after entering the practice A woman came 
in for a bottle of medicine and with some pride he dis 
pensed it quickly and deftly from the bottles on the shelf 
The woman looked at it with suspicion She evidently 
thought he had left something out Later on he had an 
opportunity of watching how his old principal did it He 
fingered the bottles carefully choosing one and then another 
with great deliberation and the pipe in his mouth added 
a certain leisurely dignity to the proceedings Probably 
the impression it made on the patient was more \aluablc 
than the ingredients themselves General practice «aid 
Dr Hughes was the practice of doctonng The specialist 
went into medicine is an intellectual pursuit and thereby 
lost some of the sense of vocation 

Tellmg the Patient 

Dr L W Batten (Hampstead) said that general practi 
tioners were the only people in the profession who looked 
after the whole person and he did not think this could be 
done by teams One of their jobs was to try to explain to 
the patient whit was the matter with him a thing which he 
was not told in hospital A cause of the frequent dis 
satisfaction with hospital treatment was that although the 
patient received proper attention he often came out without 
" ever learning the nature of his illness and accordingly felt 
that he had been deprived of something People sometimes 
spoke as if It wis easy to persuade patients to be well 
Genera! practitioners knew how difficult it was It was as 
big a «in to start an imaginary disease as it was to o\erlook 
the beginnings of a serious one The general practitioner 
had not only to introduce the specialist to his patient but 
in a sense to protect the patient from the specialist Sad 
would be the lot of the patient in the hands of the specialist 
without the general practitioner in the background 

Dr M C Andrews (\Vemble>) said that it was not quite 
fair to suggest that the consultant treated the patient in the 


zoo whereas the general practitioner treated him in the 
field A great deal could be done by getting the consul 
tant to come as often as possible to the houses of patients 
and for that reason he tried to limit the number of con 
sultants he called in and thus they got to know not merely 
the patients but himself and his own personal attitude to 
his patients Dr Andrews thought that broadcast features 
such as the Radio Doctor and also articles by Nurse 
So and So in women s journals could well be dispensed 
with but that much good might be done by bnnging togethe- 
groups of people who were suffenng from the same dis 
ability as was already done m some cases with the deaf 
or the partially blind 

Dr E M DiMOCk (Broxbourne) said that general practi 
tioners by the way they handled the family prevented a 
great deal of ill health He considered that the psychiatrists 
were making heavy weather with lots of incurables who 
might have been picked out and dealt with if general practi 
tioners had had better encouragement from the medical 
schools Dr A Talbot Rogers (Bromley) spoke of the 
general practitioner in committee work and m planning the 
medical service locally and centrally Dr St G B Delisle 
Gray (Walthamstow) said that one of the troubles with 
general practice was that the youn^ men in hospital did 
not know what general practice was The important thing 
was that young men before they specialized should learn 
something about what general practitioners did in the course 
of their work All men before they went into a specialty 
should spend 6 to 12 months in general practice 

Dr Barber in replying on the discussion said that of 
course he had not suggested that the general practitioner 
should refrain from examining his patient but without the 
case history the examination might be futile He agreed 
with Dr Hughes about the value of the bottle of medicine 
It should be borne in mind that the practitioner when he 
came into a home in which there was sickness brought a 
therapeutic influence or should do so but there was likely 
to be a return of anxiety after he had left The bottle of 
medicine served as an emblem of his continuing authority 


The annual report of the Government Chemist (H M S O 
1950 price Is) contains many matters of medical interest 
The department acts as a kind of national public analyst and 
has to solve such problems as how to detect horsemeat in 
sausages or wax in sweets and to watch over the quality of 
national flour and dried milk which it reports to be mam 
taming a high level Indeed the milling of the flour has been 
slightly improved since there is a drop in its fibre content 
the Vitamin B, continues at just under 3;ig /g and 14 oz 
chalk is added per sack But research is also earned out 
During the Olympic Games 1948 diet analyses of the food 
eaten by 28 competitors of eight nationalities showed that 
the daily calorie intake of the athletes was on the whole 
lower than that found at the last Olympiad in Berlin One 
Mexican was taking only 2 100 calories while one British 
competitor had over 4 600 A suggestion that old worked 
out gravel pits should be filled up with dust sieved from 
household jefuse was studied to see whether land could 
thus be reclaimed but analysis showed the dust to be up to 
53% organic mailer and expenment yielded a polluted water 
Some of the investigations are more adventurous Ambergris 
the calculus found in the gastro intestinal tract of sperm 
whales which have been feeding on cuttlefish is being studied 
on behalf of the Discovery Committee By the analysis 
of fluorine in fossil bones it is possible to go some way 
towards dating the skeletal remains of prehistoric man and 
the department has been busy in this way on the Swanscombe 
skull and the remains of Piltdown man An attempt to 
decide whether potterv found on an ancient British home- 
stead about 2(X)0 vears old was made from local clav was 
inconclusive the x ray diffraction patterns of clays and pots 
were studied and trace elements estimated m order to make 
comparisons of the composition of both pottery and (ocal 
clay 



36 J\N 6, 1951 


Correspondence 


Appendicitis 

Sm — I rcid the 'trttclc b> Sir Cecil nnd 

Mr Peter Childs (December lO p I't-S7) utth much inicrcst 
but with 'll! respect 1 feel 1 must comment on one or tvso 
points first out of f iirness to m> htc chief Jimes Shcffcri 
nnd secondly \% n result of m\ o\sn cxpcnencc 

It IS correctly st ited ihil t!ic number <if dcillis from 'icute 
ippcndtLiiis r'lpidly fell from 7 0^7 in lOlS to I O/p m J94| 
lliis SS1S folloucd by n stsiionir) period for three ycin 
In ^ further fill b'*! in uhich Is contmulnj, ind the 
hlest i\ III iblc hpurc (Pt 7) shovss \ 401 deiihs they also 
stitc thil the two penotU of irnprosemcnt were due lo the 
iniroduilion of sulphommides 'ind perntjllin rcspe<iivcl> 

If 50 why the three yeu mid \\^T period when there was no 
lack of supplies of nniibioiics A more hlely explanation 
IS tint csicuiicd children sscrc scattered over the country 
commonly awn from parental supcrsiMon under th'‘ cxrc of 
osensorled and often elderly prnctitiorers, rod svrth only 
cott ipe hospjt il facilities in n any cases Sulphornmid'*' 
and penicillin have doubtless helped but oihcr facto t arc 
of impofiancc in this welcome reduction m mortahiy »\ I 
base alrculs suppested in a recent article (Chr S I'>*0 
19 IK2I 

Parenls pfactltlon'‘rs and xurpeoas all played a part W 
ncbicsinp ihis wcIcutc Imptosemeni*— parmti I'e au e they now 
but rarely pour caoor od into unwd’np itomachs praciiun ief> 
on ac«.ouni of earlier dinpnoos and a preaief ^•‘^r rf mpency 
and suffcons tv-cause the danper of tie ruVofihimdi n^dosl 
of imnrdiaic operation on nil cases h inaeasinph appreciaied 
and cxpei.innt trcaiment i npldl) csmsulcrcd in cases who ote 
too liie for the early operation nnd too early for itic late on** 
Sulphonamidca and penicillin nl o deacne credit In felpmp to 
control infection 

Il is silted If the diafnosis is nppcndiciiis and if it is 
cicnriy not chronic operation is urpent lliere is no place 
for expect ml treatment Also we arc reminded Ouit 5lncc 
I adsoented expect int treatment in an iriiclc in 1*^17 the 
follow inj, hasc been adiled to the siirpeon < arnnmenlanum 
sulphonaniidcs penicillin mtrasenous drip thcripy and 
gastric suction It is obsious that these new asfddions arc 
just as s iluablc in eases treated expectantly is for those 
opented on it any time The three cases referred to in the 
article m which the expectant treatment of appendix 
mass filled were certainly unfortunate but over t hrge 
senes of eases at least 90% were found to subside with the 
recent additions lo the surpeon s nmiamcntariiim 
As ulmiticd in the irticlc nprcndiccctomy is noss always 
possible if an immcdntc operation is performed It is 
stated Where m abscess w*as found surroundinp the appen 
dix the appendix was removed whenever possible also in 
the ease of an appendix abscess ilic appendix was not 
removed unless it was rcidily accessible llicsc piticnts 
having survived the exploratory opcrition presumably 
submitted to a second operation for appcndtccclomy 
There arc many otlicr points one would like to raise but 
spice forbids so I conclude with and endorse the slitcmcnt 
of J imcs Sherren who after twenty ycirs experience at the 
I ondon Hospjtil vvroic in one of his hs! papers (/JrU^s/t 
Medical Journal 1925 I 727) The only ch'inpc I have 
made has been to greater conservation and more patience in 
dealing with ciscs of appendix abscess — I im etc 
London VV I R J McNl ILl I OVI 


Bmtwt 


Admittedly (he most important adverse ficior in morbidity 
and mortality m acute appendicitis is late diagnosis The 
next most impoftirii uticf e factor is the indiscriminate 
employment of the mmcic split mcision This incision his 
been liuphi in our mcUicul Hhooh and practised all over the 
country since operjiion fust became rccoynucd as the correct 
tfcaimcnt for acute appendicitis >ct it is a bad incision 
with little lo recommend it 

11 c eomnionesi caui'* of deaili In aaifc appendicitis is inicsthsl 
olntiucilon Tins Is due to rvrpnniiis cider localir d or 
icnciahred and now bappdy airenaldc to consnleraV'^ conuol 
hr d frnod crapy pastrre su-iion and miravrnoas dnp ibcrapy 
llu the icndcacy in intn ma! olntrucuon n ar-ravated b> iraum 
to tv-dcmsiDut tiinres In th'* Pco-caccal anpJe at tie urn'* of 
o»w-faiion esp^tsdy |o the Uu iaJi of ll " I'-um In il presence 
of flcti ely ^wol'en and cvrderrjtous (issues ii is often verv ill'll 
cull (o deliver lie appendix from tic retro cac».al or p-'lvic 
po\ ions (It ^ commonni) ihrnu*h ih'' Imnled esposme of the 
iimu‘c sp‘it metuna and ev^n if Pc laciuon ii entarp'-d bv ibe 
Uiilfffod ‘tun on frir ’e-cuiiihr rnethixl th** de-asioa to do 
so t\ ft at*c 0 tt> fthrr cons derabtc tnurra has oeeuffcd TV 
ir«rc slidul tl e surp^u i iV leas is th" trauma but no suffcon of 
esp^n ft can lool 1 a V. over lit career and rot rreo'-ea rsny 
diP» u!t t luc-lea to d'‘livef an appendix 11 rojfh a r'uscl‘*-splu 
h ii on Mo CO rr It - o'^raiion fo a-n.ie appea is piv 
ei tret ll e (faif’i''2 of^iaiioa for 1 ou e surf^^jns ard rcpisuars 
all oscf th- coiiftlry ami lo loop at (ley are taught to rralc this 

It cn dev loo Hfd I le a"d Iram bv Nrirr ttrertrrce ard 
1*^' mo (ality rale fror^ am c apperdnui wHl rot improve 
It U rot su'' "srri lo maVe a diapnosii of am c appendi iiii 
Tie surpeon s* ou d assess in bn m f'd as far as posub'e the 
position of d e nppeoiht and (he probahl*' cxicni of oedema end 
indura ion of surri uri'in- tissv.^ the I'^j^ih of his o y hemp ih*" 
noi! irpt-*rt*»rf fa to to Var In m nd TV r-isin shnu'd be 
p^an»'td aecofdmtl) In of cases It will be fou"!! ilat iV 
rifht psrarvshan Incrtion es'endi'^g from tV l*vel of the 
umbilicus to ore inch a'xwc the pul s wil pivc xn casv and 
xdequsie cxposiue threuch whuh lie caecum nnd tenmmal deum 
cxn V t^ntly c»evaied and drawn towards iV r'ltllme with 8 
minimum of trauma triJ tl e aptvcndix remostd ro mxt cr in what 
poiiuon It msy be Centlcness In tie bandlmp of acutelv 
iiiflanKd us ues (s iV kev lev ihe fimler reduction in nornhtv 
in nevie appendi lUv It is also th** key to ih'^ redotinn of 
wound infeciion winch is more ctvmmon in muscle sp’it sncssioos 
whJ h irijidre irtt»*Xion som**imn fo ctfU than in patnmetlisn 
Incltlont, which require none If a locah ed appendix aVeexs in 
(he right ihac fossj reruircx drainap^ a muscle sphi Jncision over 
It IS ibe besi approach Stmibrh in a late esse In which (he 
appendix is pnbed (o he in (h- hiph rctrocnecal or px^acf^hc 
posmons n Rutlicflord Monson incis on c** Inlth is the best 
opprovch In nil other insMneex the pnran'xltan In^sion ts the 
b^t pirtiaihrl) so for the pcUic appendix in wlu h coriect 
dhpnosis is so siften delayev! 

Tlic musJe sphi Incision as a routine mus po It is a relic of 
the pxs of (lie bxd old dnys of indifferent anxexthcsia 

Hie rccommcnt^tion of the muxcic split incision for ncutc 
nppemhcitis iv dcbatiWc Its recommcndnlion for chronic 
nppcndicitix is bid surpicnl tenchmp The luthors ndmit 
in Tnblc IV tint m 12 out of 39 cases so (rcited the 
'ippcndiccx were normxl on pxtholopiCTl cximination WTiv 
then the muscle split incision md whit wis wrong with 
these 12 pilicnls *> In all rises of co called chronic nppcndi 
citis the parnmcdiin incision should be nnde so thii the 
pelvic organs nnd tcrmmil ileum md mesentery nn be 
examined nnd the pill bhddcr and kidncv pxlpited Many 
patients who b ivc subsequent opcnlions for pain in the richt 
side of the abdomen nhcady bear the tell tale small scar m 
the right line fossa of which they and their surgeons were 
once so proud but with which they nrc now so disippoinicd 
—I nm etc 

Amcrvham m.ck, UonrRT StRXNO 


CORULSPONDCNCn 


Sm —Sir Cecil Wikeley and Mr P Childs arc to be con 
gratuhted on their 217 eases of appendicitis without a death 
(December 16 p 1347) A benign gremlin must be looking 
after their eases for in combining a recommendation of the 
muscle spill incision with a condemnation of expectant treat 
ment in late cases they arc surely doing a disservice to 
surgery 


Sm— Sir Cecil W^kcley and Mr Peter Childs (December 
If* p 1347) hue igiin focused attention on thiv important 
subicct T do not think it is sufficiently realized how 
ignonni the general T’ubhc is of the svmploms of 
ippcndicitis and how prev dent is the pernicious custom of 
liking a purgalivt pirticularlv castor oil wJicn abdominal 
pain conies on rour recent cases have shown me how even 



Jan 6, 1951 


CORRESPONDENCE 


Bxmsit 

Mcdicai. JOimUL 


37 


among intelligent v.ell educated people this dangerous trust 
m the castor oil bottle persists sometimes 'A'lth disastrous 
results 

Case 1 — A woman 75 years of age had a central abdominal 
pain accompanied by vomiting The pain moved to the nght iliac 
fossa next day Her daughter a school teacher gave her a large 
dose of castor oil on the following dav and the symptoms 
became much more severe her doctor hov,ever \\as not called 
m till the day after A few hours later I removed her gangrenous 
perforated retrocaecal appendix a faecohih was l>ing near by m 
the poorly walled-off abscess cavity in the right iliac fossa and 
peritonitis was spreading Drainage of the abdomen was neces 
sary Severe paralytic ileus ensued and her condition was pre 
carious m the extreme for a fortnight Fortunately with chemo 
therapy " gastric suction a blood tran’vfusion and intravenous 
fluids she rallied and eventually made an excellent recovery 
Case 2 — A man aged 48 had crampy pains in the 
upper abdomen following a hearty dinner Next day the pain had 
shifted to the right side He took a large dose of castor oil 
and though his bowels moved the pain grew steadily worse He 
called in his doctor on the afternoon of the day following 
By this time he was feeling pretty ill and was extremely tender 
in the nght iliac fossa At operation that evening I removed a 
perforated retrocaecal appendix from a well walled off abscess m 
the nght iliac fossa and drained the abdomen with a stnp of 
corrugated rubber down to the appendix sue He made an 
uninterrupted recovery after a full course of pentallm and 
sulphonamides 

Case 3 — A woman aged 72 and extremely obese had central 
abdominal pain and vomiting Next day she look a large dose 
of castor oil The pain became worse and she was admitted to 
hospital late that evening Her urine was loaded with pus cells 
and she was observed for some hours as a possible case of right 
pyehtis Tenderness and resistance increased m the nght iliac 
fossa and 1 operated on her on the following day At operation 
a gangrenous perforated retrocaecal appendix was removed and 
the abdomen and abdominal wall drained She made an 
uninterrupted recovery 

Case 4 — A man aged 69 had central abdominal pam at 
3am following a dinner party He vomited and in the mom 
ing he took a large dose of castor oil The pain moved to the 
nght iliac fossa and became severe His doctor was called in 
that evening at 7 p m Two hours later I removed an appendix 
lying in the subcaecal position 6 m (15 cm) long black the whole 
way with a faecohih blocking it at the base and the lumen full 
of dark fluid Local penioneal reaction was slight Fortunately 
the removal of the appendix was easy and recovery was 
uneventful 

These cases illustrate what has been noted frequently 
before that castor oil taken for abdominal pam which 
happens to be the start of an acute obstructive appendicitis 
acts in the abdomen like a match applied to a powder maga 
zine It stimulates a vigorous peristalsis and so accelerates 
the progress of necrosis of the appendix wall at the site of 
the obstruction (usually a faecohih) with consequent per 
foration and discharge of the highly infected contents into a 
peritoneal cavity which sometimes has not iiad time to 
prepare effective barriers 

As no one can tell if colicky central abdominal pain is 
not the commencement of an attack of acute appendicitis the 
administration of a purgative particularly castor oil in such 
a complaint is obMOUsly an extremely nsky and unwise 
procedure There would seem to be considerable scope 
here therefore for members of the medical profession to 
enlighten ind educate their patients and so help to lessen 
the dangers of this disease and also give the surgeon a 
chance to remove the appendix before it has perforated 
— I am etc 

Edinbursh J A RosS 

Economics and Medicme 

Sir — T n the man> discussions that preceded the introduc 
tion of the National Health Service speakers rarely talked 
finance and when they did were not infrequenil> rebuked 
that we were righilj more deeply concerned with ethics and 
high principles Some of us fell that m the course of time 
economics would enter the picture Hopes were pitched 
high on the pro'jpect of bicger and better hospitals fine 
equipment great oppommiiics and no financial restnctions 
All this might have been possible m an expanding and 


flourishing national econom> However for man> reasons, 
including inflation and the cost of defensive rearmament the 
funds have not been available Boards of governors have 
been placed on a restrictive budget new buildings and 
equipment have been deferred and expensive preparations 
such as penicillin and hormones curtailed to essential needs 
As to general practitioners financial terms of service have 
produced hardships and serious negotiations are afoot If 
inflation proceeds these hardships will increase Even a 
socialist medical association has sent a telegram to the 
Minister We want increased salaries and belter working 
conditions As to consultants those who have looked 
entirely or largely to a fixed salary by the week or by session 
do not find financial conditions easy Those who still look 
largely to private practice may have noted that Harley 
Street as always tends to reflect general economic condi 
tions and that higher fees proportional to inflation are not 
popular Consultant trainees arc- finding few staff vacancies 
as the hospital service has not been able to expand as was 
initially hoped 

What does the future hold Current articles in economic 
and financial journals take the view that adequate increased 
taxation to meet the Government s financial burden is not 
feasible and is apt to defeat its own purpose They turn to 
xthe question of cutting Government expenditure (although 
It IS more realistically a problem of stopping it automatically 
rising) and they end How in these circumstances can the 
Welfare State survive ? Some point more directly to the 
National Health Service No one knows the future but 
all the trends point to the danger of a lower economic status 
for the doctor unless some reorientation is possible I would 
suggest the need for a permanent economic advisory com 
mittee including economists to study these problems 

My own reflections are as follows financial conditions for 
hospital residents and registrars were determined by the 
existence of a large body of ex Service men They should 
now revert after an appropriate interval of notice, to those 
of the order believed adequate m pre war days Marriage 
for the young doctor could reasonably be deferred until the 
age of 30 unless special circumstances determine otherwise 
Moderately senior consultants might consider whether they 
“ could give up some of their hospital sessions to make room 
for a proportion of the trainee consultants This might 
involve some temporary hardship but a return to a more 
balanced proportion of private work would in the long 
period prove generally beneficial and prudent 

It may be that sufficient private work would not come to 
all and some reduction of fees instead of augmentation 
might call temporarily for harder work and less reward In 
my view under these circumstances there will always be a 
number of patients who are willing to pay for such pnvale 
consultations and the argument that there are not enough 
consultants for the national health scheme no longer holds 
This might also be the trend of events in general practice 
Interest in insurance and provident schemes for meeting ill 
ness should be revived and encouraged The pendulum has 
swung too far and too fast as the late Lord Dawson feared 
It might and its correction will relieve the burden of (he 
Government and the hospitals and leave the profession in 
a more prudent position to maintain their proper economic 
and social status and to meet the adversities of economies 
as well as relentless economics — I am etc 

London. VVl S LEONARD SiMPSOS 

A Co-ordinated Policy 

Sir— The outcry which has been aroused by the reduction 
of the registrar establishment seems to me to show up the 
inconsistencies of our own attitude to medicine to-day and 
to the National Health Service On the one hand we cry out 
IhaT over specialization is diminishing the scope and lower 
ing the status of the general practitioner and on the other 
that more and more' specialists are required We say that 
the general practitioner should have fewer patients and a 
higher capitation rate which means more money as also- 
docs increasing the number of specialists Is it really likely 



38 Jav 6. 1951 


CORRESPOND! NCE 


n*mni 

Mmicii Jochnal 


(Int the coiinlr> nn illord nn> hrper Mim fur tlic Hcillh 
Sen ICC 1 Js It not more lit.clj tint in> incrcuc of the 
illotmcnt for the nho\e purposes would tme to come b> 
rcndjiistment of the present rite of rcmimention ? Oupht 
we not to In\c i co ordimied pohej with priorities? 

We deplore the pip between jcncril pncticc on the one 
hind ind hospitil ind spcciihst pnctice on the other hut 
in) ittcnipt It or siipRcstion for hridpinp the pp is 
cflcctiiel) opposed not b> the idministritise side of the 
Sen ICC hut b> one side or other of the profession 

It IS Slid too tint the hospitils cinnot function without 
their present niimhcr of repistrirs Hut do they function 
an) more cfHcicntl) thin the) used to do with smaller 
numbers 7 In spite of n mcdic-il ind cicricil stiff preater 
thin c\cr before it would ippeir to he usinl for at leist i 
sscch to clipse iftcr the disthirpe of i patient from hospital 
before i letter is sent to his or her doctor Inscstipitlons 
ire neccss iriU more seirchinp thin the) used to be but 
much time and monc) arc Iwinp wasted b) blunderbuss 
invcstipitions and b\ patients proccedinp from one sp'cnlivt 
to mother (Is it neccssir) for i phyliciin to refer in 
isthmitic to in illerj ist for sbin tests i) 1 here seems to I e 
1 tcndencs for consullints In hold ippomtmenls at is nun) 
hospitals IS possible with the nilunl result tint the) ire 
unable idequitcl) to supcnite the worL at ins of them 
How nre loo it ssould ippeir to be in some clinics for an 
out piticnl to pet beyond the rcpistrir and yet it is often for 
the consultants experience ind opinion that the patient is 
sent by the pencril priclitioner Is not the term sp-cnlisi 
becominp more ipproprnle than that of consullinl — I 
im etc 

K C 

n C G nnd Sarcoidosis 

Sir — I was tnicresicd in Or I F Crawley s report 
(December 16 p 1361) of three cases of eolti'ioi nodostm 
IS a mimfeslalion of Iloecl. s sircoidosis 
Tlie recent isiilibility of (ICG (ues the physician iddi 
tional help in provinp a dnpnosis of sarcoidosis Sulrberper 
ind his co workers (/ until Ptrm 1949 (3 *••'>) base 
shown the differences in local response to 11 CG in cases 
of conpcnitil and acquired luberculin anerpy Secondly 
nCG Mccinilion will not consert the posiine anerpy of 
sarcoidosis to normal tuberculin sensitisily (normerpy) — I 
am etc 

rUcisarc Middlesex C D Csisss 

rrjllicmn Nodosum 

Sir — Dr r r Crawley s inicrcstinf paper (December 16 
p 1361) once more ruses the question of the acliolopy 
of this disease Perhaps my cspcriencc mas throw some 
light on this Since iqit 1 hue been treating erythema 
nodosum with silaniin k with the result ihil the condition 
has clcircd up in from one to three days flic dose of the 
vitamin appears to base little influence 10 mg of the 
synthetic vitimin twice daily ippcars to be as cITcctivc ns 
larger doses Those cases seen in the first few days cleared 
up within 24 hours Those who had been ill for weeks or 
months took up to three days Unfortun itely I have only 
hid eleven of these cases in five ycirs md up to a few 
months qo was not in a position to obtain accurate 
prothrombin estimations — 1 am etc 
Ilclfasl T A Kl AN 

Waiting lists for Tonsillectomy 

Sm It IS a matter of concern how ifie many children 
waiting to have their tonsils and adenoids removed arc to be 
treated in view of the 1 ick of hospital beds in which to 
put them In many localities the w iiting list runs into 
thousands and children have been willing so many years that 
vve may expect to see their offspring appe iring in the ENT 
climes soon Some I have seen grow out of their disibility 
and doubtless many children could be better trcited by con 
valescent treatment m the country with proper diet and 


environment but this seems to be unobtainable New 
Zealand I read has arranged these facilities and I think if 
vve had them we could save i lot of hospitaliralion, with its 
preater cost I would life to put in a pica for a consideration 
and development of this type of tre itment for patients bt/ore 
they become in patients — I am etc 

txipiJoa vv I C llAvinik Thomas 

Introducer In Wood Tmnsfiivlon 

Sir — Since we have used polythene tubing for blood tranv 
fu ion or other intravenous work it has been found that the 
introduction of i needle into n vein and threading polythene 
tubinj thiou)h it iv a ihoroiighly clumsy pro-edurc 1 have 
therefore designed an introducer which is illustrated here 

The Itindle o^ th* introducer is about the sire of a 6 ml 
hypodermic vvrinpe md has the same feclinp when handled 
It gives complete control of the needle "nic male end of 
the inirodi'icr is a Kccord sire to fit the ordinary 



M RC donor needle Ihrouph wliitli eitl cr sire 1 O'" Z pol) 
thenc tubing can be inserted The handle of the introducer 
IS yrooved (which is not seen in the photograph) and the 
tubing hes in it When the handle is gripped the tubing is 
therefore ptevcntesl from slipping backwards and forwards 
in th- reedle Wlrn the reedle has teen inserted into the 
vein the introducer is disconnevted and the polvthcnc tubing 
introdiivcd as far is nescssaty thfoi gh tl e needle The 
needle iv then removed leivinp tli' polvthcnc tubing m the 
vein md is taken off the other cm! o' the tid mg so that the 
tubing can then Ic coniievtcd to the gisini apparatus Tins 
polythene introdircr was made for me by \Ilcn and 
llanburys and lias 1 cen tlioroiighly testcsl and found to be 
extremely sitisfaclory — I am etc 

\trc E ilLsxuL 

CiS gfsirt R -aij TiiO lusisn OmKr 


Death from I xsanRuino-transfiiMon 
Sir — I torn a study of the literature of cxsangtimo 
transfusion in adults and from corrcsponilcncc with us chief 
esponent Dr \1 llcssis it would appear that the manccusre 
IV almost entirely free from risk We consider tlicrefcre 
tint i faliluy irising from this operation should be reported 

In n ssmiian of 41 siilleiing from neiile monocytic leukaemia an 
cxsangiiino Irinsfiision calculalcd to replace 9sn( of ihe paiicnt s 
blood was planned Caicful physical mil radiological cxanilnaiion 
prior to Ihe ii|ierauon failed lo reveal any conctiricni disease 
Thirty five pints (19 f hires) of blood were evthamed at a single 
session over iht course of sis hours the paiicnt liemg licparimzcd 
and the blood given into boili nrms while wululrawal was clfevicd 
by n ssidc bore poly diene cannula m the left femoral sein Prior 
to the opcraiinn the paiicnt had rcceiscd sis pints (3 4 lures) of 
packed cells which had raised her haemoglobin lo 13 p 0 
During the course of the transfusion Ihe patient des eloped 
sympioms of tcinny which were pronipily relicssd by iniravenoiis 
injections of calcium gluconate These svniploms recurred on 
three occasions and gacli lime required n Inij cr dose of calcium 
ghiconaic mirascnoiislj to effect relief At the end of the 
cxsanpiimo Irnnsriision symptoms of Iclany njain became 
mamfest nnd nllhoiigli they slowly suhsuled iificr administering 
n total of 120 ml 10"o cniciiini gluconate the patient died 
Post mortem cxaminalion confirmed the diagnosis of nctile 
monocytic Iciikncmin hut also rcscilcd tubcrciiloiis infilirnlion nt 
the npex of the right lung with scry early miliary iiibcrclcs in the 
kidneys nnd spleen No oilier nolnblc changes were found 



Jan 6, 1951 


►CORRESPONDENCE 


Bwmn 

Medicxl Journal 


39 


We believe lhat this patient died a biochemical death due 
to the transfusion and lhat tuberculosis played little or no part 
in the outcome The biochemical changes resulting from perfu 
sions of large quantities of citrated blood ha\e not been 
adequately worked out Certainly the amount of calcium 
required may^ be \ery much greater than the literature would 
suggest and until more accurate knowledge is available we feel 
that a warning should be given of the possible dangers of 
exsangumo transfusion in adults 
We are indebted to Drs A H T Robb Smith H B M 
Lewis and V T Pearce for their willing co operation 

— We are etc P D Bedford 

Oxford E G Lajtha 

Salicylates in Post tonsUlcctomy Analgesia 
Sir — In view of the fact that salicylic compounds reduce 
the blood prothrombin level S L Fox and G B West 
{Ann Otol etc St Louis 1948 57 1032) stale that the use 
of acetylsalicylic acid is a major factor in secondary tonsillar 
bleeding following tonsillectomy Furthermore the haemor 
rhagic complications following the administration of sah 
cylates may involve the escape of hypoprothrombinacmic 
blood through capillary walls damaged by C hypovitamin 
osis since salicylic compounds combine with and hasten the 
excretion of vitamin C 

Earlier this year I had my tonsils dissected and the resulting 
severe pam and dvseorofort were rapidly dispelled by sucking 
tablets containing acetylsalicylic aad mcnaphthone and 
ascorbic acid ( ekammon ) which were recommended by the 
ENT speaalist and no haemorrhagic complications developed 
S Shapiro (7 Amer med Ass 1944 125 546) estimated that 
1 mg mcnaphthone will counteract the prothrombin reduang 
action of 1 mg acetylsalicylic acid and therefore these tablets can 
be employed even m massive doses if required without the nsk 
of induang hypoihrombinaemia and C hypoviiaminosis 
I am relating my personal experiences with the sole inten 
tion that others may be able to benefit from the analgesia 
afforded by salicylic compounds and at the same time be 
free from secondary haemorrhagic complications — 1 am etc 

Haslloedeo Laocs H LeaHY 

Tuberculosis and (he Health Service 

Sm — ^Professor F R G Heaf indicates (December 16 
p 1353) an approach to the problem of tuberculosis of great 
value but since his methods require extra clinics extra 
medical staff lay staff and ambulances they will find little 
application at this present time However I think there is 
a solution which is not only more economical but one which 
will improve the whole standard of medical care beyond the 
local problem of tuberculosis It is for the general practi 
tioner to practise more medicine 
The specialists in all branches looking at the small field of 
their own specialty continue to press for more buildings 
more clerks more equipment and a great deal more money 
as hospital finances show And still they proclaim that 
the general practitioner is the backbone of the profession 
The general practitioner alone can integrate this health 
sen ice which the clinical specialties the local health 
authoritv the county health auihonty and all the other 
highv\nys and byways of medicine arc disrupting through 
Iheir specialism 

The home treatment of tuberculosis indeed the home treat 
ment of any disease is the job of the general practitioner 
and the district nurse the two most economical units of the 
Health Service My principal and I have already three cases 
under ircalmcnt with porn aminosalicv lie acid and dihydro- 
strcptomycin m consultation with the chest clinic One as 
Profes'ior Heaf points out, has probably avoided sanatorium 
treatment completelv and has had her disease cut short by 
months With more time the general practitioner could do 
far more artificial pneumothorax {A P ) refills for example 
Now this could be applied to manv other aspects of medicine 
All antenatal work should be done bv the general practi 
tioncr and the abnormal case sent for consultation with the 
consultant obslclnaan all child health work is in the general 
practitioner s province and the difficult case can be referred 


to the paediatnc consultant similarly with vancosc veins 
asthma the rheumatic diseases venereal diseases etc There 
IS no need for a separate doctor separate building hordes 
of nurses typists and clerks This could lead to general 
practitioners fully occupied in medicine and true consultants 
rather than to the half world of small time specialists 

In this instance of tuberculosis the chest physician should 
be a consultant preferably of all diseases of the respiratory 
tract with hospital beds under his care He secs the patient 
advises on treatment (which the general practitioner carries 
out at home) and admits the patient for short periods for 
special treatment induction of A P phrenic crush etc No 
need for ambulances — the general practitioner already has 
them available no need for the staff of the chest clinic 
to pay frequent visits — the general practitioner does that 
loo Health visitor^ I am very sceptical about A general 
practitioner with time to spare can give much better informed 
advice in this highly technical phase of medicine 

My solutions then are 

1 A much reduced maximum list carrying a similar income to 
the present This of course will mean more general practitioners 

2 A reduction m the public health and special clinic services 
These are responsible for much duplication we can ill afford 

3 A discouragement of some of the nonsense in general 
practice A scheme similar to the Australian where a list of about 
170 urgent and effective drugs arc presenbed free and the rest are 
paid for 

4 This IS not essential but just a personal view a salaned 
service Away with the cannibalism I think this would make 
general practice much happier and would help one to treat 
patients as one thinks they should be treated and not with an 
eye to gaming or losmg heads. 

— am etc 

EontyOddd F M VaSEY 

Sir — All members of the B M A must welcome the 
publication of the Tuberculosis and Diseases of the Chest 
Committees report (December 16 p 1382) It is a good 
report but it does not go far enough in my opinion on the 
side of prevention although Professor F R G Heafs xnd 
Dr G F B Pages articles (December 16 pp 1353 and 1380) 
help to fill the gap 

The scheme under the NHS is uncoordinated and 
unbalanced it is not that there is too much treatment 
there IS loo little prevention The link between the two is 
all but severed It is the duly of the Ministry of Health to 
produce a co-ordinated scheme this it is not doing As I 
stated at the B M A deferred Annual Meeting the attempt 
IS being made to fight tuberculosis on the cheap and while 
this IS so little progress can be made Payments urgently 
needed have to be fought for in regional boards and manage 
ment committees against all other interests from tonsils and 
adenoids to geriatrics and in the final allocation between 
treatment and prevention the claims of the latter may easily 
be overlooked If a special tax of 10% or so were placed on 
the sale of television sets a sheer luxury and definitely alio 
cated to tuberculosis services it would go far towards 
providing the needed funds 

The preventive or epidemiological aspect should be given 
the first consideration it pays double dividends If small 
pox or diphthena had been regarded in the fatalistic way 
that tuberculosis is wc should never have vanquished them 
and mutatis mutandis we shall only cut the incidence of 
tuberculosis bv one tenth if we attack it cpidcmiologically 
by locating the source and preventinc the snread of 
infection and by increasing specific resistance Every new 
case has contacts who should at least be tested radiologically 
and by tuberculin and if negative offered BCG A child 
with a primary infection is often such a case 

It IS true that we do not know the exact v’alue or duration 
of the increased resistance conferred by B C G inoculation 
but is that a reason for denying to contacts the protection 
such as It IS that such inoculation indubitably affords The 
fatality rate of tuberculosis in the first year of life is very 
high 36% according to Wallgren and falls rapidly till 
pubeny when there is again a sharp nse It has been showm 



40 Jan 6, 1951 


CORRLSPONDCNCB- 


P»rmn 

MftncAi latrtmu 


in Dcnnnrk pirticiihrl> Copcnhitcn lint h> \ iccimlion of 
infini coniici^ with BCG tiibcfcnlotu meninpin m infints 
one of the pnnciinl cniscs of infintilc dciths cm be 
MrtinlU siimpcd otit A'l Professor Ci mford once iml to 
me of t, islro cnicritts 1 lie children die ind nol oil) t \ic\ 

It IS not onK the -100 \vccl.I> dc iilts— ihoit^ h Ihc Home 
Oflicc uould not pit ilscll on the HilV. tf the polite hid 
reduced the sveeklv niimhcr of niurd n from ‘00 to wy V)0 
—there IS iho ihc intnien<e Ion of licdlh »nd of worlinj 
hours involved leivmj hunimiv nidc prevention of 
tuhcrcnlosis on in uleqinie venlc would he well worth whde 
The proLcss of coni at liuntinj nnd inoculition tv lime 
consuminp and requires enthuM ivni It \\ iu»t l'*int ide 
qiMiclv done md cmnoi he done wilfi cvivtinp viiHs rncdKif 
md Ollier these should he trehted to rcith the Oinivh 
viindird Sir Kohcri I’hihp iv lie P »t c f'ointx out nitphi 
thu tuhcrvuloMs w is prevent ihtc ind (hit the dopcnvitv vs iv 
the centre of uu mteinted vwicrn of tre dment and ptcvcn 
tion The present N H S vehen e is quite imdcquife on the 
prcvcnitvc side With in idcqinlc preventive v>stem fevser 
hci^s would h'* needed Is it nierelv in uhr prcjuditc thit 
prevents us from uvinj BCG ideqtnlclv ** 

Ihc resolution of iIk It M A Anninl Kepresent itive 
Mcctinp hst 'September condemnitij tlie cvislirp irriUfc 
ments for luhcrcidosis w is pissed umnimouslv \| the 
summer scientific mectme Professor He if pathips ot r Imh 
cst luthoniv stited tint we must press fo m incrdinp 
Act tint would cnihlc *i ♦'‘rvice to tc developed thd 
could reduce the morbidity md mnrtihlv if this diseisc lo 
m insqndicvnt figure Unid this is done we shdl pro~ccd 
in 1 w isteful distonlcnied md di'ordcrlv n inner w»thnt 
hope of m> red progress As Itie Scottish rommtilcc s 
report Slid this crisis must be met in itic spirit of n cfimde 
NVIut cm we do to rouse the Sfinistf> out of its compliccncy 
lo tickle this mtiom! scnndil — I mi etc 

Heswall Clie^*iirc C* O STAltMUISSS 

Ilcirt Cases in Macs Undiocnpti) 

Sir — H r Peter O 1 ct-nl ** '^rhclc iDcccrnher 16 p P64) 
niscs points of considcnhle interest to rn-duil directors of 
miss ndiocnph) units One of the most surprtsim ihmts 
in re idinp I ir^c senes of mini iturc lilms is the cstnordin ir> 
viriilion m the sire shipc md position of the t irdnc 
silhouette most of these cases ire rcpirdcd is within nortinl 
limits but numerous csmiplcs of considcnhle cnlirrcmcni 
md ibnorimhiy of the cirdiic outline ire encountered 
fn the pisf ciscs rcjirded is grossly ihnorrnd were 
rcrdlcd md cximincd by the mcdicil director who sub 
muted 1 report to the piticnt s doctor !l h is been felt how 
ever thu this procedure w,is inulcquilc md recently v\c 
hive csl ihhshcd i liiison wuh the c irdtov isi.ul ir unit in 
the Ncwcistk Generd llospitil whtre l!lc^c eases cm be 
ulcqintely invLstipUcd In ill ciscs i report is sent from 
tlic tirdiov isLulir clinic to the puicnls doctor with t copy 
to the medic il director of the miss riduqnphy unit In 
CISCS of dextrocirdii where tlic ihnornnluy v\ is nol 
known i kticr is sent to the volunteer in order to show it 
his not been overlooked — I im etc 
Newcastle up<>n Tyne 11 OlCKINsOV 

Altlcclisis mul Ilronclucclnsis 
Sin — I was interested to learn tint Or B Mann 
(December 9 p 1331) had found in eases of rever 

siblc bronchiect ISIS ihu the ininpleuril pre sure w is nol 
appreciably lowered contrary to wlut would hive been 
expected from \ perns \1 of I mcler md Dividsons (I93M 
paper I ilso observed this pnz/lmp feature not only in 
cases of reversible bronchiect isis but in pcrmincnt 
ateleciitic bronclucci isis is well 1 hope shortly lo publish 
an account of work on this subject but briefly I cinic to the 
following conclusions 

The essence of Lander and Davidson s important article was 
that when pulmonary collapse due to bronchiolar occlusion 
occurs there is a loss of spice in the affected hcmiihorax and 
to compensate for this there is compensatory emphysema and a 


ct»ni|KMiilory dilatation of the bronchi in the collap cd poriloa 
of Uinp Intiaplcuial pfcauircs are rcadinpi of ih'* jas pres urc> 
in » small afti(ii.nl pncumotlorav nnl five a m'‘asurc of the 
meioj clutic icnvion of the luni It occurred to m** tl at if 
folKwsjii" ctUlip e of a jvirtion of i! c lun^ the rcvuhinp increase 
in fhatic tcnvion vsere hr>cl> locafued to the nflcvted part tie 
coninired hfouthi mirhi t*-* dilated without tie intrnpkural 
provurc v%hch rt «• uiica tic mi>4 n tcn'ion of il • lunp Ivinr 
ii**ccatarily marked!) lowi rd ni 1 a^dcr and David on tvli^vcd i* 
wav 1 liter read the c' cHcnt flfti k bv Andfuv (1957) in which 
he stated that fol’oAinp p dmnnary collipi'* tic increwed lung 
lire c* arc in fa t (ariciv jo a* /-nJ to ihc jflcvicd aro ll/ac 
fo c U ou'*' I iln not I'chrvc ihai a low iniraplrufa) prc’ ure Las'" 
art>tfdtu to do with d c prodi wito \ of bf( In «. atta or i r cn a 
ci-ir» attiimpanim'ail of a ckitati 1 rtnit! tcc'aua I see ro 
rca oi in 4hnd I the ca cn lal fca urea of Lnader and Da idma^ 
work 

Nftifiti d pnciMvotl Of It Vs is employed on an ctp'^rimenial 
I IMS an 1 not ■udcly ilv iherapeiUi cflecl Ilie aflecicd 
bronchi were rot topMricfcd is Or Marn feared Th** lunc 
V y\ relived until llte nhhre of the dilitcl bfon(.hi had 
returned apptosu i iiclv to normt! is sIioati by broncho 
pr iphy lilts V as ilu uj-hl lo be u'equ Uc to allow c '“ipc of 
scw ctum othcrwis'' one woild lave to suppose tkai the 
nofc mitket! the 1 roiwhicvt I'la in i collapsed lobe the 
letter the prtnpccts of re cap muon 

I hive to intc"Mon of p*Tcrali/irp from Ih- reaiiUs my 
acn'*a of j'^rti sms esv-s bit 1 wvs «no*t ntcrest-d to find 
till! D 1 1 inVhn (D- ciT 1 er 9 19^0 p 135 f) Jus noted a 
Mtfiilar low It t kt ce of residual respirainry trouble 1 
entirely aprcc wUh him that it is i asatisfactory to bhme 
pertunis fo- bfOf chicvtisis on th* strcnpih of a hoio v tiken 
often Vfirt after l!i- I'eyinniPj of svmptorrs at the same 
litn'* I hive cpLOurtcred a fev cis's out of stores in vshich 
the com evton is to > clear cut to le serioi 'W doubled 
! vpericntc of brc^rcluccl isis csanvmces me that D T r inVIn 
IS coned svhen he sava that the prognosis of brorchiectasiv 
in childhood is nn eh letter than is tommonly stated 
Nevertheless | stdl think that there arc unihtcrat cases in 
vshich the dlctlion wilt le at best a rtcurrinj, muMnee at 
worst a disablnp iflUction md in which surj.cr> ImWs out 
the only rcisonable prospcvt o^ comp’ctc cure—! am etc 

0*1*1 ^ III-?* 

Urrttt as 

U-def I r k ind OivK** « M t t J h ' * P'" 11 
AnJfVi l M -t-.'f rtf 7fcV \ l*>35 38 4' 


I imp Alisccv's after riccIro-convniWve Tlicmpv 

Sm — I have read with interest vour mnotation (15 evnaber 
16 p 1577) hut I Ihmk tint it would he unwise to assume 
Ihil i r incidence of this comply ition is umvcrvil 
Pulnaoniry absLCss is indeed a serious comphcation md it 
seems strmK that if one c isc in every hundred is liable to 
be iffcvlcd so lillle attention has previously teen focused 
on It Conw av md Osmond (19, s> report one case and 
quote Kahnowski (19163 as siatinp that there is onU one 
other i. asc in the hlcrauirc In his comprehensive review of 
shock therapy Wilcox (19tS) states that pulmonary absevss 
his Icen a complication in some clinics but cites no 
rtfcrciKcs m British or AmcriLan literature In articles 
dvalUH with the technique compluations and results of 
electro convulsive therapy (F C D I'llmcr (194M and D^x 
(1919) make no nacniion of this specific complication 

In over ^000 eases iitited h\ LCT — ic double the nainihcr 
qaiotcd bv Kwalw isstr e! «/*— f have cncoumcfctl nn abscess 
in onlv one patient nnd even in this ease It was not possible 
to nttnbuie it enurcly lo I CT ns the patient had had a 
dental extraction under general nnacstbcsn a week before nclrnis 
sioia to bospitial Almost without exception, cverv ease an this 
senes was followed up for nl least n scar Atropme was nol 
used but the patient was turned on his left side ns soon as the 
dome singe icrmmated Temperature chnrts were kept and if nnv 
suspicious rase w as noted or nny rcspirniorv symptoms cxlubitcd 
the paucni was seen by tlic consiilttani physacinn and tbc chest 
X rayed 

There seems little doubt (hat the mcidcnce of lung comph 
cations during or following HCT insulin shock therapy or 



Jan 6 1951 


correspondence 


Bumsii 

Mn>iCAt JotncsAL 


41 


prolonged narcosis is inversely proportional to the standard 
of nursing In one mental I ospital m this country it was 
found that following the e treatments pneumonia had 
occurred m six men whereas no such complication had 
arisen during the same period in treating twice as many 
women When specially trained male nurses were allocated 
to the centre the incidence of pulmonary complications fell 
rapidly 

As the last paragraph of your annotation raises much 
wider issues may I as one who his used E C T fairly exten 
sively since its nccption in this country be permitted to 
express my personal views On the basis of experience in 
treating a large number of patients I feel that out patient 
treatment should be given only in exceptional cases and that 
the practice of admitting patients to hospital for ECT and 
sending them home in a fortnight or so is to be deprecated 
Even when few treatments are gnen a mild cumulative con 
fusional stale may occur during the early consalesccnce 
period The patient is perplexed and worried for a day or 
two but if medical reassurance is not immediately avaihblc 
a rehpsc often results It is well worth while to retain 
patients in hospital for at least three weeks after the last 
electrical treatment has been giscn TTic highly charged 
emotional aura surrounding ECT has in the past prevented 
a balanced and unbiased generil esaluation of this form of 
therapy The late Dr C C Burlingame (1947) that notable 
advocate of tolerance and mutual understanding among 
psychiatrists has however summed up the situation as 
follows Only a stupid person would decry shock theripy 
as an instrument in helping (he mentally ill but to 

proceed as if shock therapy any more than any other 
psychiatric technique can usurp the place of all other 
therapies is psychiatric nonsense — I am etc 

W LIDDCLL MrLLlGAN 

REfTWENCtS 


Burlingame C C 0947) / Amer mfd Ass 133 971 

Con>Hay ti and Osmond H (1948) J ment Sel 64 633 

Dax E C (l®4<>) in Rees J R (Editor) practice hjPs}c/iofct{ca! 

Mfd! tne p 357 London Butt«rv.ofth 

KalinoN ski L B (1946) quoted bv Con»ay H and Osmond H 
Palmer H (1948) in Hams N G (Editor) Modern Trends In Psyef-oiogteal 
Medicine p 217 London Buttcr^orth 
Wilcox P H (1948) in Sptegel E A (Editor) P ogress in Neurology and 
Psichiatr} 3 363 New York Orune and Stratton 


avoided Ihen the patient could have been safely tided over 
with morphine for the next two hours and the usual 
abdominal delivery of the foetus and placenta earned out 
follov^ed by a subtotal hvstercclomy I assume that plasma 
IS available in Ibadan — I am etc 
Church Village ROBFRT HODklVSOV 

near Pontypridd 


Manubno<stcmal Joint in Rheumatoid Arthritis 

Sm — Experience with Dr W S Tegners patients in the 
Department of Physical Medicine of the London Hospital 
confirms the views of Drs A Bogdan and J Clark 
(December 16 p 1361) and supports the statement by J J 
Conybeare that in rheumatoid arthritis any joint may be 
affected 

Sinfe September 1949 11 cases have been seen of involvement 
of the manubno sternal joint in patients knovvn to be suffering 
from rheumatoid arthritis Of these only one case occurred 
in a man There appeared to be a seasonal inadcncc as two 
cases were first observed in September three m October and two 
in November 1949 two m January one in April and one m 
May 1950 

As the authors point out the pam has to be distinguished from 
other causes of chest pain and one of our early cases had been 
submitted to cardiovascular investigations and a diaphragmatic 
hernia had been considered In this region not all swellings 
which arc lender arc necessarily due to rheumatoid arthritis and 

lender fatty sweibng may be found lying over the manubno sternal 
joint 

Two further points of interest were noted in our cases Seven 
out of the 11 patients gave a history of cough and five of the 
patients also had involvement of certain of the costochondral 
junctions with local pain and tenderness and swelling In three 
cases the left third costochondral junction was principally 
alTecicd In another young woman with active rlicumatoid 
arthritis but with no involvement clinically of the manubno 
sternal joint there developed such a marked swelling and tender- 
ness of the left third costochondral junction that the patient 
was afraid she had a growth and was only reassured when the 
swelling subsided in about even weeks 

— I am etc 

Loodoo E ! M Q BiRKBCCK 


Treating tlie Ruptured Uterus 

Sir — I have rend and rc read the article by Dr A H C 
Walker (November 25 p 1205) describing his method 
of dealing with a ruptured uterus occurring in labour It 
appeirs that he inserted his hand through the rupture 
earned out i podalic version In the abdominal cavity and 
then draeged out foetus and placenta through the vacina 
A vaginal hvstcrcctomy was then performed and the patient 
died after three days 

Dr Walker states that he carried out these procedures 
because he suspected that the uterine artery had been 
ruptured and that the patient could not survive until the tire 
facilities were available — a matter of two hours Here I 
disagree with him Jt was clear that the uterus had ruptured 
some three hours before Dr ilker saw the patient — i e 
when the pains suddenU ceased In rupture of the lower 
seement bleeding occurs /rom torn sinuses and occasionallv 
from the utcrint vein but rarely from tearing of the utenne 
arterv and if anv sizeable vessel is torn then bleeding is 
profuse the svsiohc pressure falls to ^0 to fO mm He in 
about half an hour and the patient is exsanguinated within 
one and a half to two hours unless the bleeding has been 
deal with siircicallv This is in contrast with rupture in 
the upper s-cment through the scar of a classical caesarean 
section in which case the uterus acts as its own haemostat 
when Us contents have been extruded into the abdominal 
cavnv and time can be spent m rcsusaiation 

In the case reported the blood pressure was 80/40 three 
hours after nipture therefore she had obvaouslv not 
nipturcd anv major vessel but was suffering mo‘“c from pen 
toncal shock than from actual blood loss If rupture of the 
utems h id been diagnosed from the history and the 
abdominal findings and vaciral examination had been 


Rcgisfj^rs 

Sm — Why has no one stated in the controversy about 
registrars that the vast majority of these jobs were simply 
created in order to provide experience for young doctors who 
had grown rusty in the Forces'^ The appointments were 
made not to meet the need of the hospitals but simply to 
remedy rustiness Surely therefore many of them ought 
to be abolished five years after the war 9 The appoint 
ments of house surgeon and house physician will then be 
more instructive and responsible — I am etc 

ColchcJtcr M E LA^(PARD 

Sm — Only a short time ago (although long enough for us 
all to realize the truth of what was said at the time) vour 
leading article wisely pointed out — one might almost say 
pontificated — the unsatisfactory terms of the National Health 
Service both in administration and in the doctors role Wise 
letters also filled your columns on the matter but nevertheless 
as the appointed dav drew near a sudden scurrv for cover v as 
mad« by all but a very few who remained outside the 
Service How historv repeats itself Once again vour 
leaders pontificate on the dastardly behaviour of (he Minister 
with regard to the registrars and wase Htters appear For 
the registrars encouragement I should like to assure them 
that unless firm coherent cohesive and coercive action on 
their part is forthcoming I 100 of them wiU find themselves 
in the street verv soon I would further warn that 
unless the consultants choose to support them thev will find 
themselves facing a similar unpleasant shock in about six 
months time when they will probablv receive the same 
degree of comforting editorials and letters — I am etc 

B=poa-oa-Tr st. R Ll'VT 



OIUTUARY 


Bwmn 

MirxcAL Jo<,»»i4L 


\2 Jan 6. 1951 


Obituary 



U a.(ef tx’ndoK { 


Sir PHU IP PAM ON MB llChir 
Sir Philip Pinion con'iitim; pitholoii'.t lo the SIiniitr> 
of He ilth tlicti It floiirnc f ml on December 27 

Philip N'otl Pinion w n born it Wirclnm, Dorset 
and MIA cdiicited it H irroM lrinit> Collcpc Cmi- 
bridge inci St fhomiAS HiHpitil He qinhfied in 
1901 ind indintetl MB, BChir a icir liter After 
holdmp the poAiA of hoiiAC p!i>sicnn at St TliomiAA 
and hoiiAe Aiirf eon 4it Addenbraolc a HoApilil he 
obtiinal 1 I oiiiA Jenner reACiri.h AeliohrAbip in pilho 
loe> at hiA oMn old teahinp acIiooI ind i Gibion 
rcAeirth scho! irship at the SocieU of ApotfiecirieA 

He MIA then ippomtcd 
iiAiAtinl director of the 
clinieil hbontoricA at S' 
Ihomi", but •horil) 
iftctMirdA joined tic 'till 
of the 1 oiidon HoApitil 
Mhcre for nnn) jeifA he 
avia chiijcil pi!bolo>iM 
ind director of libori 
loricA He ptibliAhcd a 
number of inijvirnnt 
piper A ind Mrote the 
Mell bnoMn textbooV, 
Cliiucrt PitrfinhnA the 
uitliorAliip of Mhieh he 
Atnred in liter cditionA 
Mill) ProfcAAor J R Mir 
r icV Diirinp ind after 
the A-cond Morld Mir 
Pinton idMAcd the MiniAlr> of Iteillh on the 
CAtibliAhment of pitholopicil AcriieeA lo meet the 
ncedA of the CMS and the detulcd bnoMledRe he 
E lined ia he Ment iboiit the countri Acned him in 
Eood sleid uhen phni hid to be nude for the NitionnI 
Health SerMcc Man> mcdicil men ia mcII ia hjnien 
concerned Mith hoApiliI idminiAtnlion tnuAt hi'c met 
Sir Philip Panlon on Iiia aiaiIa to hoApii ils ind Iibori 
torics and been imprcAAcd In Iiia cultured urbinit> and 
hiA ittenlion to detiil cicn at the end of a lonr md tirinf 
d I) He Acned on Acienl imporiint commiiiceA of 
the B M A , including the Centr il Cmergcnc) Com 
mittcc, the Ccninl Medic il Wir Comniillee and the 
PoAlgridii itc Cdiicilion Committee J'or Iiia AcniccA 
to the MiniAtrj of llcilth Pinton m ia I nil tiled in 19lfi 
ProfcAAor J K Mirnct. MritCA 1 Insc Acen the 
groMth of the clinicil hboratory of the London Hoa 
pint under Sir Philip Pinton a direction from 1909 until 
he left in 194f) He had found \cr> hiptn/ird irringc 
ments when he cime but he tjuicblv hid orpim/ed a 
Iibontory thit wis ible to copt Miih anj demindA 
that clinical medicine mide it tint time Under hiA 
guidance it his continued to meet the c\er rrowing 
deminds ind to undertake rcscirch o\cr i Mide field 
Sir Philips interest wis in medicine as a whole, 
liborilory work to him was in aid in the understand 
ing and dngnosis of disease ind the treitmcnt of 
patients His book Clinical Paitiolog) which first 
appeared in 1913 showed his outlook it did not as 
did most books of thit time include i multiplicity of 
tests good and bad but only those that he had found 
useful It was compiled almost wholly from his own 
experience — written, as he told me, in bed in the cirly 
hours of the morning 


In those days ssith a less croMded course students 
Mho wished to could nlc i post as clerl in the dim 
Cil libnritorv I tool this post in the hot summer of 
191 1 Punton made those three months most interest 
inp md silinble like mmy others I hive owed a 
grcit tleil both then md in the \eirs after to his 
intcrc t ind cncourit,cmcni He mis tinustialK ibic to 
appteciite other piiplcs points of sicw m scientific 
mitters and to reili/c the silue mil imtiorlmcc of work 
tint MIS not in his line and hid no immediate appli 
cinon in dnpno'ts or treitmcnt This ind his general 
interest in mcthiinc mide lum m excellent intcrmcdiats 
between the mo c specnii/ed Iibontory workers md 
cbnicims md between niedicil m-n md hymen 

Sit L! ONARD PARSONS M D . F R C P 
! UCOG, rR5 

Profes or Hilili I lovd PRCOG wriies Siriconird 
Pirsonss interests in the mlicil world were so wide 
lint there is no bnnch of m'dicinc thit will not feel 
Ills loss His contribiitjons to pacdiitrics were so well 
rccopiirnl by the Royil College of Ohstctricnns and 
Osmccologists thit he wis idmiltcd to the Fellowship 
of the Colic) e in 19-SS and it tint time deliscrcd an 
oiitstindmp lecture on mtcmial pacdiitncs His interest 
in the cite of the ntwls born during the tim" he wis in 
chirpe of them at the Sliicmity Hospital Birminchim, 
hid the foundiiion upon which the present dcpirtment 
Ins been built up AUhoiith his nstes in medicine were 
citholic perInpA none of them were of grcitcr worth 
thin this hiA own pirticuhr choice He had an uncom 
mon facility for picking out soime p omisine juniors 
and mmy owe i greit deal of their success to his help 
and cncoiitaiement m the earls disi of their careers 
So piAscA a greit friend of south md not imnatunlly, 
one who retiincsl his soiithfiil outlook m ripening age 
J C S writes Leonard Pirsonss life ssis like a rice 
sscll run Ouiclly stcidfi'tls md moUestlj n went on 
from siicccAS to success He siss carls that paedntnes 
could nnkc greit contributions to the teaching and prac 
ticc of medicine that it ss is one of the bulw irks agimst 
cxsessisc spcinlism mil he designed bis circcr to those 
ends In one of bis nre but delightful moments of self 
confession he told me lint it was on a return journcs 
from Amcrici sshcrc he Ind leirned so much tint he 
SISS how m rnglisb hospitd michl design its ssork to 
combine rcscin-li icichiiig and pricticc in m itmo 
sphere of tonirulcAhip Ihose s'ho worked ssilb him 
in Birniinibim ssill know best how quickly be did this 
to nnkc liiA bospit i| one of the most fimoiis md h ipps 
picdiitric LCnlrcA in the world But it wis obsious to 
ill of UA ssbo I ntss him lint the aucccaa of his dcsicns 
ss IA itbicscd as much through the ssirmth of Iiia chanty 
iiA throuih ths cijcrncsA of Ills mind Hess is mils both 
1 grcil physician and i bcloscd min In 25 scirs of 
riptniiig friendship 1 ncser heard him speik ill of my 
min, nor any ni in siy ill of him In ihcsc w lys he 
Went on gilhcring fame, and alwiys a little surprised 
tint It came is it did So many mcmoricA of Parsons 
crowd till, mind thit it is dilTicult to choose but 1 shill 
cherish alwiys tlic spontmeous kindness of his rtnnrks 
to 1 youngi-r mm it the list meeting of the British 
Picdi itric Association In that frmkncss of discussion 
which has charnctcrircd the Windermere meetings the 
young mm hid been somewlnt roughlv handled md 
Parsons sprang to his defence with words of priisc, 
advice, md cneouragcmcnl that enriched the day He 
endured unfalteringly, so that none of us could belicAC 



Jan 6 1951 


OBITUARY 


Burrait 

MiCICJlL JotTLSAL 


43 


his age It was therefore fitting though tragic that his 
life should end suddenly on a Sundaj morning when 
he came home from his chapel, ^^armcd himself at the 
fire and died 

HENRY MacCORMAC CBE \ID FRCP 
Dr G N Meachen writes I had not long been 
appointed to the staff of the Blackfriars Skin Hospital 
(then in the old premises in Stamford Street) when a 
tall, pleasant looking young man cime one afternoon 
to my clinic and asked, somewhat dilTidentlj if he might 
be allowed to sit with me to see some skins ’ I quickly 
discovered that here was no casual postgraduate hoping 
to pick up a few crumbs of dermatological 1 nowlcdgc 
but a real student of what was then almost a neglected 
specialty, anxious and willing to learn all that he could 
It was not long before I felt sufficient confidence in my 
new clinical assistant to lease him in charge of an occa 
sional clinic Thereafter I watched his upssard progress 
with the greatest interest ind I rejoiced to sec him mount 
the staff ladder at the Middlesex Hospital He was 
indeed a loyal and lovable friend 
L K w rites 

Steel true and blade straight. 

The Great Artificer made my mate 
Henry MacCormac and 1 were close friends before 
the first world war and it was sheer delight to me at 
Wimcreux, where 1 was in charge of a hospital in 1914 
to find that he was establishing a slin hospital at 
Hardelot Plage some 20 miles away His work there 
was almost superhuman and was greatly praised especi- 
ally as he was able to send up to the front m a short 
time manv hundreds of patients who would otherwise 
have had to come to England to be treated He will be 
much missed for not only was he a brilliant dermato 
legist but a most amusing companion, sparkling with 
that Irish humour which is inborn and cannot be 
acquired He certainly had the courage of his convic- 
tions and his great enthusiasm to carry a point was 
always admired His quiet pcrsonalits was irresistible 
and his smile at times insidiously enchanting he was 
indeed a losable gentleman 


Dr Alexs'.diir DALRsasiPLC McQueen who was for many 
years m practice in Blacl heath Birmingham died at his home 
in Birmingham on November 23 aced 74 years McQueen 
entered Aberdeen University at the acc of 16 and graduated 
M B Ch B in 1898 Before establishing himself at Black 
heath where he remained for 50 vears he practised for a 
short time in Oldhill Staffordshire He lived to see very 
great advances m medicine and sorcery and could recollect 
when major surgerv was performed in the homes of the 
patients He vvas interested in Ihc worl of the St John 
Ambulance Brigade and was the first d visional surgeon 
and lecturer to the Rovvlcv Regis Division Well Inovvn as 
an examiner at competitions in the West Midlands he was 
recently awarded tie lone service medal He was a skilful 
and conscientious practitioner to whom the welfare of his 
patients was his onlv concern His somewhat austere 
manner cloaked great kindliness and benevolence The 
Black Countrv has lost one of us oldest and most able 
practitioners and he wall be greativ missed in the distnet 
where he wo ked for so manv vears Dr McQueen leaves 
a widow and three dauchters — J P 

Dr Ti'ioaaia Gerrvrd DEVirsEV d *d in Dublin on 
Novemb-r 25 19'0 He gradu-ted MB BCh at the 
National Unive'sitv of Ireland in I9-.I and h-!d vanous 


hospital appointments until 1943 when he joined the staff 
of the Grove Park Hospital I ondon It was here that his 
interests became centred on tuberculosis and he quickly 
showed an aptitude in the field of clinical research This 
led to his beinc associated with the first clinical trials in 
Britain of PAS and it is in connexion with this form 
of therapy that his name is best known Thereafter he 
devoted most of his time and energies to the study of this 
new weapon in the ficht against tuberculosis He vvas 
invited to visit the Continent America and India where 
hu delivered addresses on his experience with PAS In 
1948 he joined the staff of the Mayday Hospital Croydon 
Here vvith his special knowledge of the chemotherapv of 
pulmonary tuberculosts he instituted a new regime of treat 
ment and inspired his co workers with fresh enthusiasm 
in their difficult task He never spared himself at anv time 
in his efforts for the welfare of his patients and constantly 
overtaxed his own limited phvsical strength on their behalf 
Finally his own health broke down in November 1949 
During long months of illness he never lost heart and 
his own keen interest in medicine did not diminish His 
characteristic humour never failed him and when he knew 
the end was in sight his courage was an inspiration to all 
His charm and sympathetic manner endeared him to his 
patients and colleagues and his death at the early age of 
34 IS a loss to the medical profession as a whole and the 
tuberculosis field in particular His many friends will wish 
to express their deep sympathy with Ins widow and two 
young children — L hi K 

Dr Gilbert John King Martvn consulting physician to 
the Royal Mineral Water Hospital Bath died at Paignton 
On December 5 aged 81 years He studied medicine at 
Cambridge and the Middlesex Hospital graduating M B 
BCh in 1894 Three years later he proceeded M D and 
also took the D P H After qualifying he became a house 
physician at his own hospital and was later resident medi 
cal officer at Queen Charlottes Hospital King Martvn 
Went to Bath in 1898 and vvas in partnership for a short 
tiac with Dr S P Btdd who died the following year 
For nearly 25 years he carried on a large residential and 
spa practice In 1913 he vvas appointed physician to the 
Royal Mineral Water Hospital a post that he held until 
his retirement in 1922 During the first world war he was 
so over worked that his health broke down and although 
il vvas completely restored by a sojourn in the Balearic 
NIes he returned to Bath for a short period only and fin illy 
retired from practice in 1922 when he went to live at 
Draguignan in France King Marty n was a member of 
the B M A and vvas president of the Bath and Bristol 
Division in 1920-1 One of the eight founders of the Bath 
Clinical Society in 1908 he became its president in 1913 
He was a keen fishermin and was interested in the arts 
cspeciallv painting and music Of distinguished presence 
and courteous manners he was popular v ith both his 
colleagues and his patients He was twice married his 
first wife dying about 30 years ago — R W 

Dr Arthur Edwin Rvinc medical superintendent of 
Bishop Auckland General Hospital and part time assis ant 
senior administrative medical officer to the Nev castle 
upon Tyne Regional Hospital Board died suddenly on 
December II in the hospital for which he had done so 
much since Julv 1948 He was the son of R W Raine 
J P of Middleton in Tcesdalc and he studied medicine 
at Newcastle upon Tvne graduating M B B5 in 1916 after 
a oistinguished academic career in which he obtained 
honours in all his professional examinations Soon after 
graduation he was on active service in Salonika and in 
1918 he was invalided out of the R A M C suffering from 
malarial fever After thi he spent a few years in Sund— 
land in general practice — an excellent preparation for his 
future career vith the Durnam County Ccunal and with 
the Newcastle upon Tyne Regional Hospital Board For 
2 j years he gave able and devoted service to the courty 




U Jas 6, 19<;i 


OmiUAUY 


mctlieil olliccr in i.lnrj.c of its putilic ismOhhc mnlinl 
scnicc! After llic Ninonil Itcilth ScrMic Net nine into 
force in 1‘ttR Unne liitJ tno oiiisiriulinr profcvtionil 
intircslr In lin iipuii) n meiliril Mipermirmlcm of 
Holiop And hnd Geiici il lloipml tic dnl rtmte Itnn ms 
oilier imlisniiinl to turn tins Itospilil ssnliin tint Omit time 
from 1 poor 1 in inMitmion mil mfiriinr) imo in tuisc mil 
sscll sfitleil pencril limpitil of Tboui '(Xl I ills wliicS is 
nlrcnils ilcnlmi with n nnior stnre (if ilic nine lospmi 
uorl. of ilic KXlOOt) people silio lisc in mil nroiiiul Ilistmp 
Aiiil Imil It SI IS a (.rnt jos to Dr H ime lo sec this 
npiil ilcsclopmcnl ami to Insc tlic lluhop AinHiml 
General lloipit il rcio, ni eil bj llic licnetsl Niii'in>. 
Coimet! as n complete reneral Irilnim s^liool for nm es 
\Im) of Ins plitis imni nos' le soiiplftci! b, olliets bin 
Ins ssisilom Ins assnreil tlie future simiss of tl'c liospitsl 
winch helil such n siroiit, place in Ins allesiioiis Kmic was 
ptoiiil of Ins unique appoinunem as pul tm e osMstant si-ni it 
iilmmislritisc meilicil olh cr lo the rcponal liospiisl boinl 
mil ss IS ttitcful for the opp irlinniv islnili it pasc Inm to 
contimic Ins sersi e for the sshotc of Coimis [liiitisri Itis 
wisilom ami Inossicil e were of the liiihcsl ssloe to the 
hniri! in the plannmr of the liospiiil crsicc for Ins 
complete anil iinimilc Inowlcilre o' the conms ami Ins 
fricmlship with inniimeral !c i 'oplc in it tase to ihe 
board m its earls >cars sornctliiri wlncli m> o'lier tl> ^to 
m the repion soiitil tnse pisen His ossn chnicit interests 
were in the c-irc of ih' arcs! sid. ami in ihts dim at 
field he ss is sl'sclopm; i rood scraice in Ilisbop Vi.l 
land mil eapedeil lo see miiili mine ainimphshcd in the 
nest fess jcirs In addition l(> Ins olher onetons sliiltc' 
Rainc ss IS atsis one of the oiiuml inciiiters of the llishop 
Auchlind Hospital Manafcment Csniii' iilee ssliiili ossed to 
him I pTcat dll t for Ins ssisc nmliti-c in the desdopmett 
of the Olher tinspil ila in the ptoiip He ss is a inn of 
great plissnnl mil ment il eiicrt) who did not spire Inmscif 
m the course of liis dunes Init sitio found resteation m 
music and liippiness in his church Ills sevcic ilint's s 
few ssedks afo was Itierefore a great surprise to Ins 
collcai-ucs and Ins sudden dcilli when he appealed to be 
pelting user llic illness ssas a great sln'sli Dr Rainc 
ihonplil seldom of Inmscif and jlssigs of oiliers csp'tiall) 
the ued sich and Ins friends ind eoHeanies sjmpitfii e 
ssith his sstdoss and Ins tssn btoiliers mil tsso sisters m 
their loss — W G P 

Dr Jons Rbssi It I ossr who died at se i on December U 
while medical ollicer of the C In of Chater ss is a pradinte 
of Trimly Collcpc Dublin ind w is Inmscif llic son of i 
doclor A good sporlsmin he Ind pliycil tinbg for Ins 
school Cimphell Collcpt Ifelfasi and (ns intivcrsiis and 
ht had also rowed for Trinilj He ssas onl) yens of 
age whin he died hasinj (seen qiiililied fniir yens In nil 
his house appointments he not onlv sson for himself the 
wirm esteem of Ins chiefs but the siry rcil gratiliidc of his 
pjlitnts His loyilly and (cncrnsiiy lo Ins friends sserc 
perhaps his most oiiislmdinp qinlilics Only tiuisi sslio 
(new him well liarncd (kiss (inilini and iinosienniioiis sscrc 
his many iits of hindness ({is trjiic dcitli it Ihe oiilsil of 
a most promising ciricr comes is i grcil sfioih to Ins 
unusually many friends — R \V M S 

G B writes A member of a family who ossc much lo 
the shill and care of Dr Robert Young AilV.cn Isshissc 
obituary nonce appeared in the Journal of Nosember V 
19501 would like to record that many pilienis will remember 
him no (css for his Kindness nnd generosiiy — qnililics oficn 
hidden by a pruffness of m inner In remembering him as 
he wcnl about Blackburn and Ibe surrounding district in 
those hard pressed days during ind after llie first world 
war a vivid picture springs lo mind of the nil ilert Slot 
leaping from car to door and back apiin for those in 
real need Dr AilKen put himself to endless trouble 1 here 
must be many who will think of him wiih grautiide 


IS# mm 

Mirsral Itraoui 


Mcdico-Legal 


SLUG! ON I INAI IS CII AltCD OP 
M GI IGI NCI 

[Igrut OLK Miriftn I ir sl Copprsro orvri 

In 1') : Mr J 1 Whiicforil an American consutlinp 
cnvineer of 05 si is lirci ired bs Mr John Ilunlcr lo bt 
sulletinr from cancer of II c 1 ise of llic bladder On Iht 
sltenjili of ibis dug nous be rclnrncd lo An c i a pse up 
his p aiiiic pul Ins nlliirs in order and prepared lo d e 
I lit Dr llenjimin Pirtintrr an Amencin siirfcon ssho «« 
I im scsenl non lis h'er found that Ins di'*asc was not ir 
fill 111 sh, net I Mr W inteford jeeo dingU sued Mr Hinlci 
fe't dm lyts altc mg re|liic'’cc ip not inine a cssio cop' 
•St prtf irnnn, a 1 lopsy Mr Jnstuc IlnVeli trying the c-se 
at Inst imlaiKe in 19.#'! au rdrJ heasy damages bin lit 
Coil t of App'il next ycir rest sed this judcri'ni and past 
Mr WIntefoiJ lease lo jppsal 10 tb" House of I onjs Boh 
healings sicie (idly repotted aid some comm-nt san the 
e t was mad n a I'atlip, aiticlc in this Ji irojl' The r 
lords* IPs Jlo has now jisen jii le-nscrl dismissing 
Mr Wbitefodi app-al’ 

1 1 rd ('otter statcsf in (us opinion lint Mr VMiiteford* 
atinnici s i\ not lint the dugro'is ssas r'ghetnt but 11 at 
the rcscnllince betwe-n real and simii'atcd cap-er ssas so 
close that ran d agnoos of canter slioii’d be accep 'J wphout 
a pillol’i ell cairn niinm A suig'on nitst exercise Ihr 
sicstec of skill and care tcasotuble fo o*'* in I is post 
tion and si chitged ssilli nc|!i.e -e could clear bimscll 
ly abosin, that Ic I Ml acted in acto dan'C with y-ncnil 
aril app sssed ptawtiec Mr Hunter lad giscn csid-nce 
siippoilcd b) |s\o eminent surgeons lint his action had 
lonformed lia tin skilled r'ailiec of ihe p ofession On 
the other hard fJ Barringer hid said that to serifs a 
diignosis ia( a cancerous gtossih a complete eaamittilion 
lay meins of a tsstos^ope ind thtoiyli the open blid.l"r 
and a piltuslognal e'aminaiion |sf any questionable area 
slimild hive b.en made that he took those steps himself, 
lliai iltey were the ordiaata and mini steps and that there 
was no di'hiiilts or ilaneer In either ispcralion 

I onl I'orter lussicser did not think Dr Bamnccr meani 
lliai air Ilunlcr sboiild hasc taken those steps in March 
or April Ibe appeiransC and state ssf the bladder at that 
time dill nm seem tis bi'c been disclosed to Dr Ramnper 
sshose answers tlid nisi supicsi chat he had in mind the 
imliinicd miss covcieil s'llti thickened mticoiis membrane 
abnormal m eoloiir dcscribesl bs au Hunter but a condi 
non liVc ibc scry shflcrcnt condition be himself had found 
m New aork Moteoscr esen it bis csidcncc could be 
accepted in full n spceinicn toiild ln\e been taken onls 
with a cysioseopc fillcil siith a ronieiir attachment in instm 
mcni scry rare m I nplind in I'Jd; and not possessed hs 
air lliinlcr All ibe [ nghsti medical witnesses bad isscried 
lint It ssas aeainsl npprosed ptacttec m (.npland lo use a 
cssiosenpc where there was acute urinary retentton and 
Ihil ssben Ibc bladder was drsmeil and collapsed tl was 
dillietill or impossible lo use clfeciisely a cvsioscope nol 
of the fiiisbing type Tins instrument also bad been rate 
in I nplind it the material lime and Mr Hiinlcr had not 
possessed one The appeal was dismissed hs unanimous 
sole of their lordships 

MOtg 2 sa? 1949 I S9S f69 

'The Thun November 19 19S0 


Persons wilbonl a selllcd way of b'inp (saprants or 
cisiialsV in Dceember 1949 ascraped 2 367 in reception 
centres of the Ministry of Nation il Insurance This was 
the first time since the war that there Ins been a decrease 
tboiieb all the post war figures arc low compared with 
formerly 



Jan 6, 1951 


UNlVERSniES AND COLLEGES 


n*rTtim 45 

Mn? CAL JOLHSAL 


Universities and Colleges 


UNIVERSITY OF CAMBRIDGE 
In Congregation on December 16 it uas decided to establish 
T University Lectureship m the Department of Medicine 
The following degrees were conferred on December 16 19*^0 
MA — \V J St E G Rh>s MB BS Janet E Bottomlc> 
MD FRCS MRCOG 

The following candidates have been approved at the examina 
non indicated 

Final MB — *R H Adnan ^ *W V Agnew *P T Anneslcy 
Armett * L J H Arthur ‘ N B Aikin ’R S Atkinson 
A M Baker, A C Bamford *G S Banwell ■ >A P 
Barefai Barton ‘A C Beatty ‘R J Bcnnison * ‘A P 

Blower * ‘M H S Bound *J W Bradbeer ' S D Bradley 

‘M Braimbndgc U S N Briggs ‘ *G S Bnndicy • ^P L 

Broadhead * *1 M Brown * *W M Browne • *K Brown 

Grant * *A A F Bryson ‘ * *W E G Buckley * ‘D M J 
Bums P Bums * *A S F Butcher ‘ *E P Cadbury 

' *M D Cameron C McG Campbell * ^P B Clark * *E R 
Coats * *R A Cooper ‘ * P H Crosskey ^ *J C M Curnc 
•*W G Davies • D G Dickson H Dickson M H 
Dickson • *\V Dorrcll * G D Dowmes ‘M F Downey 
‘*B O L Duke ’F P D Easby * U Fairgncve * * *R T D 
FitzGerald ' *R M F Fox ‘R T Gaukrogcr ^ *A E Gibbs 
*D C Gibbs “P C Glynn Jones *L Golbcrg * Goodall 

‘ *P H Gorodi * H Gough Thomas ‘D M Grant *I H 

Grant * • A Gnmsliaw * *I M Guiver ‘ *A T G Gunn 
’ B M H Hardman ^A M Hanngion * ^A S Hams 

’ *D S Harry • *G Harvey Evers ■ *M W A Hawaid 

J M Heaton • *J F Higgins ‘ ’U M P Hill ‘ * G Hirst 
‘M Hobslcy • 'C A Holborow * *M L House ‘^R L 

Huckster * *P E Huddy ’R G Huntsman * Hurst *A W 
Johnston * *E W Jooes ‘ *\V R Juckes *R Kceley *J C 
KcUej “M H King ‘R G P King •*! Kinross '*C D 

Lace) * ‘A B McGrigor * K G P Mackenzie ‘R E Mackic 

*J J McMulhn »C R Maddock • V J Marmcry »S E 
Marmion »Mrs C M Maxwell * *l H Mills ‘K H G Milne 
*J r Moor * D B Murray * *J H Newton *G McK J 

Nicholl ‘‘D S H W Nico! E M Orton • *A Pancih 

* *G G K Parsons * ’F S Perry * U R H Pinkerton 

»H r W Pnbram * E J Purcell ’ P J Randle 
*J R Rees ‘‘R H Reynolds ' ‘J M G Ritchie 
*H M Roseveare ‘ H B Russell * *F C Rutter 

J J H Rymer * H A Sanford ‘ ’G E Sayce • *J R 

Scale *J H Sewart * *C Shaldon * Mrs E C Shore ’PH 
Shorthousc * *I M Simmonds * * * H S K Smgha * G 
Smallcombc * D Smith 'I Smith *J L Somcncll * E M 

Sproston * *C M SnITord ■ P C Steel * * E Stokoc 

J D E Strong ■ Sunderland ’^P H Swinhoc ‘G A 

Taylor K A Taylor * ’B E L Tliomrsan I G S Thomp’^on 
P Tucker ‘B V Tyman * 1 M ^^atls >\V G \Senlcy 
Mrs J M ^\cston ‘ *P H \\hcclcr * *Mrs M P ^^'hltchousc 
■*! H ^\llllams *J A N\illnm5 ** R A Williams ‘R T 

Williams **>D H M Woollam ‘ * *G H Wnght 

‘Passed in pathology and pharmacologv ’Passed in principles 
and practice of physic, ’Passed in principles and practice of 
surperv Passed m midwifery and gynaecology 

UNRTRSm OF EDINBURGH 
\t a Graduation Ceremonial held on December 15 19*0 the 
following medical degrees and diplomas were conferred 

MD — r D Caldwell T M Chalmers E N Moves ‘C S 
Russell *J T R Russell ‘J J Stevenson 
M B Ch B — H F Achesen SN D A Birch G ^ ChcMie 

Phvllis Connor B S Dorfman I A Fraser A D Gentle J 

Grant E R Henry Brenda M Johnson Hazel M Lazarus 
Margaret E Loudon A M„caula) A R Manners W P Mazur 
J \ Miichcl! P T Monard R Renton P F F Rushforlh 

T M N Salves L E S Sandnon G A Steel** J F S ephen 

E B T„goe Nano M Twrcdie Siodart M,.r> B Watson J S 
WTiiitakcr T W Wilkinson 
DirioMK IV Mtdicvl R.iniornrK.vpa — J D Abb tt 
TIic followang awards were m de CncI ton f\esea^eh Sefo^cr 
rt p \ D Ro''*Tt'''*a MB Ch B Eth con Fr^ecreh sHp 

S R Mukherpr B-. B,S Grorze Gtithr e Rcjrc^ch Fr^icm 
ip tn Cht'd Hre^ h H S Prcvis, M B Ch B He i oh 
Rc<c‘^J Schc in sm B Cru-wkshank MB,, 

B r*. rr^ 7- Tf;nr ;'-e 5afrr*7- A B WJLce 

MB Ch B /trirrn Gr-h^-n Rt hte Bun^r'ics D B E~ on 
a"! N I M Browne Rus e -Cnz^tof^ Pn r K Wood 
‘In ab«o** I- Cc’—’'-**d*d fo- 


UMVERSFFY OF DUBLIN 
School of Pinsic, Trimh Colitgl 
T he lollowing candidates have been approved at the cxnmmaiions 
indicated 

MD— R W Barter MTS Conradic B V Earle H Fitz 
Gibbon J M Johnston 

MAO — C L S Archer M B Fhnagan 
MB— -L Tarlo P J Myles T H Bcwlcy A C Allen H A 
Dcvlin R W Mitchell J P B Tuohy R S W McLnmon 
D L Cowan N I uriong Sara K Mitchell D D Macdonald 
N R McNutt 

BCh — A T F (Trench O Carroll Helen M Hackman 
PEA Blake Knox Anna J Ilcndly M J Sweeney J N 
Cocknil J O Hunter AWL Pollock A Rosenthal I H 
Moore E W' Lillic R W' Mitchell L Tarlo D Romnev 
W' G Hutchinson D D Macdonald J P B Tuohy 
B AO— 'Grace M F ^orke 'R V Lea 'W McC Wilson 
H J Ncctliling Sara K Mitchell AWL Pollock N R 
McNutt 

TIic following medical degrees were conferred on December ? 
1950 

MD — R W Barter H FitzGibbon J M Johnston 
MAO — C L S Archer M B Flanagan 
MB BCi! BAO— A C Allen T H Bcwlcy J N Cocknil 
H A Devlin N Furlong Helen M Hackman Anna J Hcndly 
J O Hunter W G Hutchinson PEA Bhke Knox R V Lea 
E W Lilhe D D Macdonald N R McNutt Sara K Mitchell 
F H Moore H J Nccihlmg A T F flrcnch O Carrol! D 
Romney A Ross M J Sweeney J P B Tuohy Grace M F 
Yorkc 

With second-class honours 
UNIVERSITY OF DURHAM 

In Congregation on December 15 1950 the following medical 
degrees and diplomas were conferred 
MB BS — Meryl A Chnstnn J A Eykclcnboom J R J 
Glavina C St J L Harding Mar)oric Hepple D D Hobbs 
Shirley McTaggart B Metcalfe Shirley M C Nuttall Loh V 
Stafford Anne W' W'ails 
D P H — J F McGanty (tn absentia) 

Henry Haney Evers MS FRCS Lecturer in Midwifery and 
Gynaecology in the University has been appointed to the Chan 
of Midwifery and Gynaecology at Newcastle upon Tyne 

UNTVERSIYV OF LONDON 

Dr Vernon Frederick Hall Ins been appointed Dean of Kings 
College Hospital Medical School as from January 1 in succession 
to Mr Harold C Edwards who has resigned and Mr Alexander 
John Henqt has been appointed Vice EJean 
Mr r Bcrgel PhD D Sc will deliver two lectures m the 
physiology theatre University College Gower Street WC on 
Thursdays January 18 and 25 at 5 15 pm His subject i' 
Physico chemical Properties and Pharmacological Activity of 
Drugs 

Two lectures on Cell Metabolism and Chemotherapeutic 
Activitv will be delivered by Mr T S W'ork Ph D m th** 
physiology theatre of Univxrsiiy College on Fridays February 
and 9 at ^ 15 p m ^ 

All the above lectures arc open to m-mbers of the public 
Mr W J Cofictt will deliver a lecture oa Population 
Trends m the anatomy theatre Univcrstty College Gower 
Street W C^ on Thursday February 15 at 1 15 pjti , 

A lecture on Counting Heads — The Taking of the Census 
1S01-I9X] Will be delivered bv Mr A J Taylor m the anatoms 
theatre of Univcrsi v College on Thursday March 1 at I 15 p m 
Dr E A^hv^onh Underwood will deliver a I'*cturc on John 
Wesley nnd his Pnmitivc Physick in the anatomy ibcatrc ol 
Uni'crsitv College on Thursday March 8 at 1 15 pm 
Admission to th** above lunch time lectures is free withot 
tr ket 

Th** title of Professor of Clinical Patholo'w in th'* Univc^jfv 
has been conferred on Montagu* M-izcIs M D M R CP 
The foMowng candidates have been app oved at th- exami-a 
lions indica ed 

ACVO'VtlC POSTCXVDLVTE DlPLOMV LV MeD CVL RaDIOLOGV 
(DuGvosisl — M M Craig 

ACAOrMC PO^STCPADUTT DiPlOV V IV 'TrrvirxL PADOLrx*V 
(Tin'pvpa) — H S Ah R J Di 1 on A W Pegh- s 
Prefer- A W Daw-"!- p ofcs>o of h ** cno’''''v n tl- 
Ln vc-sit' cf Liverpool wah d-’iv-r a S'v-C’al U'Tve- v Le^urc 
on Irfee on and It — v m S—- 1*nox t‘’- I onden Sc^-aol 
Hvr— *•- and Tro"i'^l M-d a^c k epp^^ S r— ' Go#-— ■ S -n 
Londcr* W C on Fnd-v J --arv 26 at ^^0 pjn 



•16 Jan 6. 1951 UNlVCRSlllES AND COLLEGES emn,, 

_ _ l-fftnciL /oLiHit 


A (.ouinc of two ipcciil Itnitcttit) I cclurfi on lltc Itohliiin 
rtopctlici wcl I uticlioiM of t(ic Vitnmfitt II,, will (<<; dflncrcd 
hy Ur 1 I cslcr Smilli ni the School of I’lntmicy 17 llloomt 
bury Soinrc W C on Wcilnewl ly and IIitirMliv I cbrinry 7 and 
S at ' If) 0 m 

A ipetiil Unnettitt I r tine on 1 oin. Acid mil Gtowtii of 
Tiimoiirc t^pccnlU Itoiit Sinonn will Ic dclncicil by I’lo 
lector J f nrcibicih Hoini ptofettor of pithoIorLil mvomi 
In the hnnciMiv of ropfnhi,rn at lie 1 omlon School of 
llcpiene mil Iropcal Medicine on Mondu Iclruiry 26 at 
1 10 p in 

All the aboic letliiict arc addrened to t!i denn of tli- Uniter 
lit) and to other inlerc ed in tl ' nil jeett Adni tion It lice 
witlioiit tichet 


Medical News 


Kesc'ircli on Itilirrciilotit 

The innii il report for IO<0 of llie llritiOi 1 til etciili tit 
\ tocitli nit teti Itch comniitlcc iccoidt i tmtll pilot tit il 
utinp thiiwcniairb iron- on adtTnceil pt Imnnary lub-tcti 
lotit Allliotith scry popiiltr in Cictntiny tli t drnp I'lNt 
not ipp ir from pnhlitheil rep >rlt to le mtihinp hie at 
efTcclisc IS St cpioniycin Hie trtil conlirm'd the e pip is 
to the cMcnt of siicp'tlinr that lino ^miotba/o i- no, hi find 
Its tell Use IS 111 1 l|iirc ssitli sticpl ni'ycm when ;i i 
inunnsalies he acid could nnl Ic fitcn A fuller controlled 
inscsiirilion It plinncd Ilic ct'nimillec K nt o mallnp t 
siirscs antonj, sliid-nlt of I oiulon ni died schOi Is and ttr 
chest clinics lo deierniine tsliclhcr liislopI ismoti* is end inic 
in flrilain 

financtil Aid (o I’rlsalc Pnllenls 

Die Motpital Sets ice I’lin in esitlciicc for nun) yetis 
Ins 1 ecn modified lo suit pretenl dty condiliont Anyone 
stibscnbinp lo ihit irtsiirinre fond and t ho is a pnssie 
w ird in patient may recover the whole com of liotrilil md 
profession il fees up to i maximum of £210 in any scir 
Refunds are ilso mule apiinst Ihe cost of full im e hi n c 
nursing and conlrihiilors who ire icnenl w ml S JI S 
pilicnts arc dso cniiilcil to ccriiin I cnchls Ihe inniul 
Mibscriplion sines from £2 lOt lo 10 nunc is depending 
On the dcerec of cover and full dcljils miy Ik oMniited 
from Ihe I ontloii Associalion for Ilotpilil Vnicet 
Tasistocl House Soulli lasistocl Si|iurc 1 ondon N\ C 1 

Macs R idfogripht In I Ire 

Accordinf lo a rcporl in Ihe /rri/i Thncj the U-pirlmcnl 
of Health his just created a limilcti non profil mal ing 
company called Ihe Nnlional Radiograph) Associition 
which will provide a mimber of mini ilurc mass radio 
graphy mobile units to operate llirouchoni I ire svliercvcr 
the locil he dill amliorilics desire them and eonlrihute lo 
the fin inccs of the issoci ilion II is hoped lint evcntiially 
all ire IS will wish to lalc adv iniicc of the service vsitich 
IS modelled on llial worlini in Sweden Al the niomcnl 
mass radioeraph) is aire idy conducicd m Uuhlin and in 
Count) Corl / 

A Dannnion I cctiirc Tour 

At the invitition of the I’oslgr idti itc rcdcritions of 
Aitstrali I and of New /c il mil Dr \V N f'lcklcs of 
Aysgarlli yorlsliirc it diiriMg (he firs! half of Ihis year 
giving a senes of lectures in these two Dominions 
Dr Pickles will be away from Jamiiry 18 lo June 20 

In Uriel 

The new president of the /'oological Society of T ondon 
in succession to the late Duke of Devonshire is ndd 
Marshal I ord Alanbrookc 

Professor T Tcrtiison Rodger is chairman Dr A Dick 
vice chairman Dr Hunter Gilhcs secretary and Dr M M 
Whiltet treasurer of the Association of Psychiatrists of the 
Scottish Western Region for the session 1950-1 

At the annual general meeting of the Dritish Association 
of Plastic Surgeons on November U 1950 Mr A R 


\V tllxcc (I dmhiirgh) was elected prcsu'enl Mr R J V 
tUlifc fl ondon) vice president \fr R P Oibornc (User 
pooll Itctsiirer Mr J P Pcidy tl ondon) secretary and 
Mr A I) Wall ICC editor Ihe mcmlcrs of the counni 
ire Mr J N Ilarron Mr O M I ii/Cii(ihon Profesor 
( V Kilncf Sir Archibald Melrdoc Mr J S Tough and 
Mt Ram ford \fowlcm 

On Decepil cr II Ihe Uniicnil) of N irc> conferred o- 
I) Htock Chisholm Director Gener il of tlic World Health 
Or,ani/aiion Ihe de,re- of d Ktor I otuirn laiut of the 
Univci'ity and of the Med eal 1 actilis 

fh- Roy d Colic, c of Pliyuctins ) is preptred a list of ah 
the <eriil pitheaiio i including year hooks contained in 
Its 111 rirs s hitli sp cialires m Ihe history of ri eJici''e 

Mills 

Dr \ G N Well' c head of S'rciford lares lit 
£11548 I) H li Morns It c M O lo Mils dl and We l 
(In mssi h dislti IS ‘eh lo! Icfl £U 7H Dr W T At dianif 
of Osfo il £2*059 Dr II Divlrm of Shorefarahy S- a 
£21010 Dr Join kliln of Sini'erltnd £K-555 mi 
D John Clifke lite of Rotherhtri £2-172 


COMING IMVIS 
Rolieil Camphell Mrttiorbl Oration 

\ Ivsit jjt ( ottp‘'clt Mci t 'tul O 1 ion svill Is- given b' 
t letitcnanl licneral Sir Wdlivm SfacStIftur in the G cat 
Hall I'f 0 ectiv L'mse sily Relfi oa Tliiir<d.iv January 
II at Sip pm His sub cc Is \ Medual Sirvcv of Ih' 
Irish ! imire of 184' 

Goiilsfonlan I erliirrs 

Dr H J Ardftvon will d'hver ih' (nuilsioman I Ccltires 
Kfote the Royal College o' Physt laiiv of I ondon (Pali 
Mall last SW') on I tic slay nnJ TItursJav Jnnt-trv 5* 
and II it 5 pm Hit stitjftl is lul-riulnsis of lie 
Pcricirditim 

lirltlsli l’ov|(.raduale Sledicnl 1 cderalinn 

Ihe llniish PoMiradiiale Mcilicil rcdTtlion (2 Gordon 
Sniiate I ondon W C) his artin,cd a nil nl-T of lectures 
on He Scicsiifi lltsis of Mciluine co-npioitit the 
second half of ili' series win h le^in in October 19^0 
It) le delivered al the I on lot School of Hvgiene anu 
Tropi-il Sledieinc Kcpp"l Slrce Gower Slrcct WC on 
Tuesdtvs and Ihtitsdass from Jamiitv 9 lo March 20 al 
' 10 p m The Iceliires arc deM,rcil cvp ciallv fevr research 
seorkers and speerth'ts in Ironing anti ml nission is free 
witlioul Iickcl D'lails Will he piihhsl ed in tlie Societicv 
and I ccliues column of the Jotirnil week h week 

Psychhiric Aspects of Acrnmegnly 

A public leciurc will he delis ered by Professor Manfred 
nictilcr of the University of 7urich nl Ihe Institute of 
Psychnlrv M iiidsicv Hospital Denmark Hill 1 ondon SL 
on W'cdncsihy Icbriiarv 14 ai 2 45 pm His subject t* 
Acromegdy and Acromcgnloid PvyclunUtc tnd Genetic 
Aspects 

I citsumi in I cclures 

Dr S Cochritnc Shanks will deliver Ihe 1 ctlsonuan I ec 
lures before the Medical Society of I ondon (I I Chaudos. 
Street Cisendivh Square W) on rehriiary 19 and 28 and 
March 5 at 8 10 p m 

Osier Club of r ondon 

rite next mcelmc will he held it the Medical Sociclv of 
I ondon 12 Cliandos Street, W1 on 1 ridav Jtmnry I9 
1951 It 7 45 for 8pm The meeting will be in honour of 
Sir James Cnnllic the centenary of whose hirih falls on 
Jinunry 17 II will be opened with i biographical account 
by UciitcnanI General Sir Ned Cantlic Director General 
Army Medical Services The discussion will he- opened 
by Sir Philip Malison Rahr and Mr I D D Davis 
There will Vve a meeting on I riday March 10 1951 when 
Dr Hugh Sinclair will read a paper on the history of 
mitrition i 



Jan 6, 19S1 


MEDICAL NEWS 


PjLrmn 

McrjTCJLL Jo 'ILM.tL 


47 


Hcbcrdcn Socictj 

A clinical meeting of the Hcbcrdcn Sociclj «ill be held 
in the McNcrstcin Theatre Westminster Medieal Sehool 
Horseferry Road London SW on Wednesday Janiiarv 24 
at 4 pm when many of the cas-s shown prcaioush will 
be demonstrated again after one leirs progress together 
with new cases Dr J H H Cilsn for Dr W' S C 
Copeman and Dr Oswald Sasacc wiU show a short film 
on The Therapeutic rtTecIs of C ortisonc 

Nutrition Society 

A meeting of the Nutrition Soci ii will be held at the 
London School of Hygiene and Tropical Medicine Keppel 
Street Gower Street WC on Siturdaj J-'nuary 20 at 
10 30 am when there wilt he i discus ion on TlieXiom 
paratnc Merits of Animal and ScLCtahlc Foods in Nutn 
tion Tile speakers ssill n Dr Tristram (St Andrews) 
Dr Carpenter (Rowett Instiuit i Dr Blaster (Hannah Dairy 
Research institute) Dr Y lies iRothamstcd Institute) Dr 
Lucy Wills (Royal Free Hospital) Dr Harncttc Chick 
(Cambridge) and Dr Dc ms (Cambridge) 

Bnlish Association of Physical Medicine 

A two day mcctinc of the Briiish Association of Phssicai 
Medicine (45 Lincolns Inn fields 1 ondon W'C) will be 
held on Friday anJ Saturdai April 20 and 21, with the 
following prosisional provramme April 20 11 30 am 
lecture-demonstration on Micro waacs by Dr A C 
Boyle 2 15 pm meelinc at Headley Court Rehabilitation 
Centre Epsom 7 for 7 TO p m annual dinner at the Royal 
College of Surgeons of England April 21 9 30 a m annual 
ccncral mcctinc 10 30 am short papers 2 pm demon 
stration on Ultrasonics Further information may be 
obtained from the honorary secretary of the association at 
the above address 

Medico lAigal Society 

The annual dinner of the Medico Legal Society will be 
held at the Sasoy Hotel Stnnd London WC on Thursday 
January 11 at 7 IJ for 745 p m 

SOCIETIES AND LECTURES 
A fee is charged or a ticket is required for attending lectures 
marked • Application should be made first to the institution 
concerned 

Mondaj 

fssTinTTE or Mn\idslc> Hospual Denmark Hill 

I ondon SC— January 8 ^30 pm lecturc-dcmomtntion b> 
Dr C Stcnrcl ^ v. 

Mrmeu SocirtY of Losoos 11 Chindos Sireet Ci'cndisn 
Square London V* — Januan 8 8^0 pm d^cu^sicn 

Unfjtreefed DrrfJi FoIIo'n/n? Orc^fltion \o be muodu-rd 
bN Dr^ Kciih Simpson and I\*an MapiH 

^^T HosriTAi St Georpe s Circus Southwnrv. London 
8 4 pjn, Opticz {RcMsion) by Mr H N 

Reed 

♦Rosal r^T IIo'iriTAt S Gcorpe s Cirais Soulhn-ark I ondon 
SC — JimnryS ^,30 pm Arctomy of the E}e erd Orbit 
b> rrofessorT Sjcol 

TctsdflT 

RRmcii Po'^TCRinuATC Mfdical Federatiov — \t London School 
of Hvpjcne and Tropical Medirne KeppeJ Street London 
V* C ianu^rv d 5,30 pm The Sxenificcrce of 
r/:n/irr rr c Cftr'nfrc! Trc'iimiUer of the Effects of Amc 
Sir Hcnra Dal- O FRS 

CtirLsn CitMrM Socirrv — At ^uth Kcn'nrtcn Ho el 47 
Quccua Gate Tcrmcc London S NN Jan\.arj ^ 7for7w0pm„ 
coloured cmervMoerarh film Dsr-tsh Exr^orrti'*n in 

NcTjf-crn Green^crd to be de— ons rued b> Mr Ebbc MurcL 
IMs^nmr or D RvuTOtocn Ude S ret Le-nr^cr Square 
London V* C— J-nuar^ 9 5 pm„ The Fyoserc Co ct tn 
Derr'^ t Vcr b^ Dr J O O’lTtr 
Ro\al Coarrr or P^iY’itcjavs of Lnsix^v Rail Ma*) CaU 
London SV» — januar. 9 5 p-m ** TuVrcu’ojfy of the Fert 
es^d GouR o-i n Le'^i.'e bv D H J A^d '^on 
Ro^^t r^T Ho«JTrrAU S- G*cr{r s Crrus. Sou h-«*a 1. Lo-don 
S E — J-ni 9 * pTn„ Str^pr^ of ii e Fr ''re b\ 

Mr T M 

T\edre<d^ 

OI\<nrTn.nT o^* ATOirvj’i Lis^* S e- L- ere* Sq*. re 

Ic-don V* C — 3a-.i.*% 10 ^ p-n, \ rev Tr*^f q /e bv 
I> C M kr— V 

Roml V\r ffn^rrTAL. S s CTut Sou 1 Lc*’don 

Sr ** Fr*n e- c! Fj*'0*jr*e b^ 

Mr R r C*7vJ. 


Ro\al rActUTn or PuY'atciAN^ Avo SuRCroNR or GLAsro\\ 742 
St \inccnt Street GtaA"o*\ — J'tmniy 10 ^pm 5>mrtoir^ 
tn Ccrdiac Diagnosis I mltison ^^cmorlal Lecture b> Sir Jo'in 
Parkinson 

Royal MicFoscoriCAU Socitrv TaMUoA Hou^c Sou h TqmUo k 
Square London C — Jinuar> 10 f pm niectinp of Ibo 
lopical Section ^ftcro dissection Sluates on imoch-^e by 
Dr Joan torch 

Royal Sasitary KsTinnr 90 Ruckmrham PMicc Road 
London — January 10 7t0pm di^cu^iMon 7Ae//ricfif 

of Poems in Dncf/mcr in Rcfnfion to Ifcnlth and Comfort 
to be opened by Professor G P Crowden 
Society or Ciir iical Imilstry Food GRour — At Medical 
Soacl> of London U ChandoA Street Cn\cndi^ti Square 
January 10 2 15 pm loinl mcctinp of the Microl loloncnl 
Panel Viith the Society for Applied Bactcnolo^ S\niro<ium 
The Ci/o’ocy of Uecterla 1 arerr b> Dr C Robmow 
Mr C 6 Moms Dr F CosAlcti and Dr K A Risnct 
Pfofc<sor R J V PuUcriaR syiH op^ the discussion 

Tharsda) 

AtrscD Adler MroresL Soritn — \i 1! Chanilos Street 
London W j‘»nuary 11 8 p m A Gei rm» T/icor_> of Human 
flehaMour b> Dr M G Good Discussion to be opened b) 
Dr James Moore 

British PosirRAOUATT Medical Federatio t — At London School 
of Hjricne and Tron cal Mcdianc keppel Street I ondon 
\V C Jamiarv U SiO pm Sreefnf Proftfemi of Chenucat 
TronsmisJ/on o/ r/en p E/Tec/j 6> Acery 'c/io7nr Adrcnatuie and 
btorairenaUne^ by Dr \V refdbcrp FRS 
Dovcasttr MmtCAL Socinn — At the Danum Hotel Doncaster 
January 11 7 for 7 15 p m nnnual dinner and dance tn be held 
m conjunction v.aih the Doncaster DiMsIon 
©IssTnxrrr or Dermatoiotv LhIc Street Icicester Square 
London \\ C — January 11 5 pm Patholo}:} by Dr J O 
OIiAer 

IssTiTim! OF Laryvoolocy A' d Otolooy 310 Gra> s Inn Road 
I ondon W C — Januara 11 5 pm Otitie Barntrattn o b> 
Air Commodore C D D Dickson 
Liv'Erfool Mepjcal Nrtitutiov 114 Mount Pleasant I i\cr 
pool— January 11 8 pm papers Chemotherapy in 

Tuberctthsis ' bv Drs O F Thomas R M Todd and C A 
St Hil) 

Physical SoettTY CoLOim Grole— A t Lecture Theatre 
Tnstutite of Ophthalmoloey Judd Street I ondon VV C 
January 11 5 pm $7th Science Mcctmt: Cofuiir I /sfon 

Characfertstlcs of Ei:\nllan Trichrnmnls b> Dr I G H 
Ishak (Ibrahim Pasha University Cairo) 

Ourrs s U'»ivrRstn (Cpfat Hail) Belfast —Januarv II 
810 pm A Afedicof Sunrv of the tnsh Pamine of 
b> I leutenant Genera! Sir IVilliam MacArthur 
Royal Army Mroicst CoiLrct — At I ccture Theatre John hhp 
Street London SW Januarv 11 5 pm The SiRntheance 
of Anaemia by Sir Lionel Ululb) 

Rosal CoLtrrr or PirYstctAVs or Iokoos Pall yfall Fast 
London SNV — Januarj H 5 pm Tithercidods of il r Pen 
cordium Goulstonian Lecture by Dr H J Anderson 
Royal Eye Hosfitau St Georpes Circus Southv.arl I ondon 
SC —January 11 5 pm bfethods of Examination b> 
Mr C M Shaflo 

St Georges Hospital Medical SaiooL H>dc Park Com'*r 
London SW — January II 4 30 pm Iccturc-dcmonsiraiion on 
psychiatry 

Torovay and Disttict Medical Society — A t Torbav Hospital 
Januarv 11 430 pjn clinical meeting 

Friday 

•Royal Cvt Hospital St Gerrp** s Circus Southskark I ondon 
SE — January 12 5i0pm F/njft7’o*> afther\r 
Royal Medical Socim 7 Melbourne Place Edmburph — 
January 12 8 pm, bfyocardiaj Ischaemia dis'-rtaiion bv 
Mr Philip Kessl> 


BIRTHS, MARRTAGTS, A^T) DEATHS 

EtRTTIS 

Mjt— D “cnN-r 17 19^0 it C'^aU'A’a Kcrt to Dr 

dorr— Jr MacKe-n ) w tc rt Dr G A- (Ic^ 1 Mir * 


ARRTACES 

Oisawk— r*wcTtl.— Dn D-c-r*** If 19 0 at S*»r**t* 'ti’xn T»t5* 
IVnirat \Nu a-i ta Rub ct Fayccii 't D PS 

DCH 

TITl— Pwwt,— O* Nio^c^Ner i*! 19 0 it ih- Pin h Oar N St 

Fi 'r C?rk Jr*-- fem F j- HH »t B COi U7 Itijh Road 
Leya*- E. to fjiTt: era P-m. O'" t at Sec*i Ork 


McTray*— -O^ 

S-''— 'i-'d N i;:TTaT M 
*vriL— |- 
SFd L.Rrrscr«t 
Oa D**er-S»^ 
CCTTlt. Edwi l3 V*Ti 
r»a tm — O- D --1— 

Pa kt Str NnC pi— ; 
%»pzk»a.— 02 t>-cc~*' 
0*n Te*'— _3 
ar*d 41 

TW r — Oa 0-c*r=-^ 1 
'LB PO I Pi,k 


DEATHS 

19 ““ at S o '^-•cr^Avn- Do-^aJd 

D Cd Terrs Co*jr* S *a’*C!'<J-r-vATaa #ra! 75 
19 0 r — r* LOkid^s Sn* OBF L R C P A. 
cf '*1,* ‘d % akc^^d 

U 19 0 at I? Fz!r-“c*d Pcad Crtyiimi SrT*T 
•-T QBE FP Ci! a* d ft 
77 19 '' at 1:4 bcss* 0*^-*, Pa*! p/rr* Erd 
- 'LB„ BCh. 

■*13 19 9 at S'-Tr H'w-'ju Ci«s^raa Art** r 
Va'-r'-s MB OB 3 n~» T , Cr*t 


I at V t h-— JcYr S's: 
Hicc A Plrarr^h 


i V.> ^ OBF 



LI'lDl MlOl OGY SI Cl ION 


•iS Us (! 1951 


ttrmti 

Mfwcii 


Ll’mi MIOI OGICAI NOT CS 

Smallpot at ItilKliloiv 

Up li' J ininr> 1 (6 pni) II c’tici of ^roillrttx incluflinp 
one dc-tlli Im\c been rcj'ortcil in llic rcn"n of tlfijliion 
llic infctlion II llioiijlii lo Inxc been inltodiiced an 
RAI iitlKcf who Hew [(om Kifichi to 1 coebti' life 
xhirc hndm^ there on Ninciitbei 11 I'i'O He hxd teen 
nceiinlcd in Oaolier I'Ho [wo .h)x Inter he inxelKI 
lo Urithli’n b) rail artel Uli ill riorini lie jonrtie} offer 
inj, from nioix No M(nx or mniptonm (.luruicrKti of 
nmdipon dex eloped tlioiiph he ix mo) to luxe Ind n xpnr r 
nxh no* xeen hx i doeior and le win ticxtcxl xt Unehloii 
for nnlirn lie xioicd friendx al llrtihi. n rrHiitievI fo 
leiRlntx on December C xxeni to KinKox Mi'is^xhue 
on Defend er It nnd then rctorncxi lo Urn h on on 
D-Rrcmbef 21 

Mcimifiile on Pet'rnbcr 12 a xxorian i(cd 27 txho i 
he Ind been Mntin). fell ill She Ind lud ion)ii''xiixmx 
for ixxo dixx nnd went x''l dol> xxn Id xcnxt '- 1 12 ttnxVxo^ 
thil the nnlxne lint xiitled on lint dxd xux due lo the 
conjtinclixilix Mie xialexl at Iiort - tiniil Dexernbe H xxlen 
n fexx xpx'Ix xtcxclop'd and xhe xxjx xcnl (o ho ji j| SitnII 
pox xxax xluinoxcxl on Oceernter 2‘> Ihe raxh wax ar^pi j| 
and Ihe x)iriplon x were fluid On fdxeeniler 27 her falter 
aped « IX idnnftcd (O hoxpifxl xerj ill Viidi in efjthcina 
loiix ind ti leinorrh ipic taxh he xlird on Id ernter 21 
rmher nnd dun liter Ind leen xaceinxled onl> m Infancj 

On IdCxeniler 2'> two n ore xa'ex 'xcre dninixed— a 
xxonnn friend of (he dii!(h(er aped xfont 2< xxho Ind 
helped to mtrxc her K home xml a nnn xiho Ind I ecn 
uolinp the firtiil) On Ideicnil-er 1(1 one of the riirxex 
M the hoxpinl d,.x eloped xnnllpox and xo x'rx the xamc 
di> did I xxonun xorrer xiorhirn at i laon tr> (o txhieli 
the oflierr X ilolhcx lud leen enl on tdicenxl f tt On 
December 31 three more c-ixex xvere dnrnoxed -two xxomen 
xotterx (tom tlw xime Ixondr^ and anoiher ntifxe it the 
hoxpifal On faniiir) I xmal/pox >x u draprroied in i fhird 
nutxc fxxo of ihexc ntitxex lud nexer leen xacematexi 
and the tlnrxl once onl) in childlioo 1 

Potlonijelldx 

Notifications in the xxcel, endinj Idexembcr2'' Ifso xxerc 
pard>tic 3S (R2) non piril)lR I' (2'*) total J3 <t07) 
The fuiircs in piicnlhcxex are Iho c for the prexioiix xxeel 
Uncarreilcil rioldic ilionx for Ihe corrcxpondmi xsccl. in 

1947 nnd 1949 xicrc 60 and M rexpiClixcl) Total im 
corrected notilie ilioiix for |9S0 to ind iniliidim; the xxccl. 
under rcvicxx 0 x 8 643 TTic toriexpondinx finiicx for 1947 

1948 md 19t9 xxcrc 9 1 17 2 3S6 and 6 79| rcxpexlixcl) 
Coiinij ircas xxiih the laricxt nximber of notdnritioiix xxerc 
I ondon 6 and I xxcx 6 flie ririrhed fill in the fipiires 
cctuivaleni to a SO reduction conipired xxilh the prcxunix 
xvxcl. IX very salixf>clor> 

Infliicnrn 

TTicrc his been a marked prex ilcnec of influcnri in 
Scandinixn from cases of xiliich ri virit' (ns been txolilcd 
not unlike the A prime slnin xxliich ocxiirrcd m this 
country m 1949 The dixeast his hxen of a mild txpe but 
with a hipli attick rale Ilipli incidxni.es of inOiicnri luxe 
also bexn rcporixd xxithin recent xxxxks from xcrl <in pirls 
of the USA Northern Spun Sardinia Persia nnd 
elsewhere 

In the absence of notification of influenza the incidence 
of pncumomi ciscs and deiiilis from pneiinionn and 
influenza are used ax a puidc to the prex ileiice of the 
disease and the following figures may he xif interest 


Great Towns j 

1 pneumonh fnchidine 1 nniary Infltienra 

Ca^c< j 

Deoihs 1 

Influenrat Dentha 

Week cndtnR December 9 

347 

23r 

3t 

Week endjns December If 

274 

283 1 

33 

Week endins December 23 | 

363 

350 

54 


1 \\ *Iet 

f (Pririary ind 

Civet 

Ue<V. »o } ff t)^tir t«rf 9 

! 

rrxsiA* |>«strr »vr tf 


g IVver ^rr 2) 

i M7 


( iliex and lux nx xxiih the larpext number of pneumonia 
nolihk ilom for llr xxceV ciidinp December 23 were 
fsindon 4; Siind'Tfind 24 Ndweaxifc 23 flirminpham 
20 Mxneliexct 17 Si eflictd |5 lucrpoof 14 
Allhointi i)ir>e xijiiiiirx afford nt> cldTCe of an) lermiK 
oiiiltrak o' I ifiiicr a in lliix eountry up lo December 2 j 
in (fie lait xxc'*k or rtiorc the dneax-' lixx been scr) prcxalca 
xn the no th eaxi and a rinl-c' of Utpc lovmx haxc beer 
liti ineliiJ nr Sun ''tiard Durham nnd Sexxcaxllc upon 
l)nc ft •cernx lilrl) (hat ih- xfixeao- hax spread lo l' n 
area from V iruhnavn and hloralory x'udicx ma) j’mw 
th" xiiii' X run lo l-e njcnli al xuih il at tn Sr-imhnaxra 
tt e di'caxe tn the north eaxt app'xrs to he dixtinet from 
the sr xallcd inlh ra a at p exeni xxidexp ead rn other parti 
of tic lOimir) lie infec ma ma, sp'ead southwards ir 
lie n'XI few xsecks 

Uoail Sceldents 

Aieiifdinp ro tie kfirix r, of Trarxport 483 people vxc'c 
killed In load ac.i lc"U in (Ktob"r |9S0 ax compared xxi h 
T‘0 in Oviol>ef 1949 Thme injured in road acciJenix ir 

0 uiKt 19*0 numherc I 4 S4S x'tioi xl) injured ard 12S7P 
tfiphtf) injurcif f oricxp'ird nj f cures for Owfober 19x9 
arc t (18 and II S|4 U.loh-r 19*0 had the hipheii 
liiiinie r o' n id caxinl les fo an) O lo''er since the xxar 
In Nose ilet 19*0 the ptoxoional figure for deaths ix 484 

>\teV J ndlnR DtccmhcT 16 

tor drill cor<".iilixc xicckx th' mctd'rcc of d)'cnterx 
hax tixcn in I nrUnd xnd \\ xlex and durmp the xxcek end 
inj Dveemls-f 16 a new tceoid wxx cxtabhxhtd xxnh 1 2!4 
tiolifi itmns A further rue ii* Ihe number of notrlimtron* 
of nietxlex and iihi>opinr coiiph xxax record'd and both 
ilirsc due lies are al an exxep'ionatl) hipti Icxcl for this 
period of the >car \ lur xnx recorded tn the incid-rce 
of xrarlet fexcr and aiutc pneutvoma but the staxonal 
tiemlx of tbexe dixeaxex arc unuxuall) low Of the *0 cases 
of dipMheria in Injlind and Wales 14 xxerc notified in 

1 ancixlofc 

The fill m the nolifualionx of aciilc pohom)ehtis xxax 
clicckcil a rise of T xxax rceordcil and the total xxas the 
largest number notified during an) liflieth xxcek TTic larpexi 
of the loeil tixcx of acme poliomxchlix durinp the week 
Were 5 m Siirte) and 4 m Kent in the latter coimix 8 
of the 10 cixes were notified in Orpington U D 

D)scnlcry 

Ihc larjcst returns of d)xcntco dunnp the xxcek in 
InjIind ind W'llex xxerc 1 im-axhirc 262 (Southport CB 
82 Oldinm C 11 28 Rixhton UD 28 Irlam U D 2f 
Salford CIl 23 Great Harwood U D 21 1 xxcrpool CR 
20 Middleton M R tfil I ciccxtcr'liire 239 (I eicxster C R 
196 M irkcl llarliorough R D 11 Harrow upon Soar R D 
10) Torkxhirc West Riding 132 iLatb) U D 48 Saddle 
worth U D 20 1 ccds C 11 10 Shelhcld C R 10 Rndford 
C» 9) Shropshire 8a (Shrewxhur) MR 20 Whitchurch 
UD 10) I ondon 52 (Ishngion 14 St Pancrasll) Surrex 
17 (Mildi-n and Coombe M R 20 C-shtr U D IS) Durham 
40 (Dirlmgion CR M) Miihllcses 40 (rdnionlon MR 
29) Monmouilixliirc 40 (Ahercarn UD 20 Newport CR 
15) Wirwicksliirc 39 (Ritminpham CR 33) Sotkslxirc 
I nsl Riding 37 (Klncsion upon Hull C R 34) Cheshire 34 
(Mnccfcxfictd M R 91 SiafTordshirc 28 (Clieadie R D 9) 
Torkshirs North Ridinp 23 (Middlexbroiiph CB 15) 
Norlhaniplonsliirc 19 (Corh) UD 13) Esses |8 (Rom 
ford M R 12) W'lhshiri 14 (Marlborough and Ramsbiirx 
R D 8) Cumberland 12 Glamorganshire 12 Glouctsier- 
shire 1 1 



Jan 6, 1951 


EPIDEMIOLOGY SECTION 


PufTmi 

XtrvCAL JOLTtKU. 


49 


So «0 

iNrccnous diseases and vital statistics 

Wc pnni below a Sumnnrv of Infcchous Diseases and \ita1 
Statistics in the Bnlish Isles during the week ended December 16 

Fiinirci cifPrinaral Notifiable D 'eases f jr the '»e<’k and those for ihecorre* 
sponding Week tail year for (a) Lnelard and VS ales (London inctoded (b) 
London (adminisirat ISC county) (c)S<oi(ard (d)I ifc fr) Nonfern Ireland 
Figures of nirthi and Deaths and of D ilhf rrer l^t u d tjch JnfrrtI ui 
dlifa\e afe for (a) The 126 great t wTis In Cn land and VS ales (inctud ng 
London) (b) London (admlnlitrati ccounty) (c) The 16 prin'i'^a) io«os in 
S^tland fd) Tlie 13 principal Iomtis m Lire (c) Tb 10 pnrciniJ loisns In 
Noni ern Ireland 

A dash — denotes no cases a blanV pace denotes disease not notifiable 
Of no return a\-ailable 


Djscdte 

1950 1 

IV 9 (CorrcipondineWrek) 

(«) 

(b) 

(c) 1 W) 1 (cl 

(a) 

(b) 

i (C) 

i(d) 

fc) 

Meningococcal infec 
tion 

Deaths 

29 

- 

i ! 

14 1 1 

37 



17 

3 

1 

Oinhihcria 

Deathi 

SO 

4 

-1 

, - — 

9‘‘ 

1 

14 

31 

3 

4 

Dysentery 

Death) 

I 214 

32 

I47j 

1- 

197 

13 

73 

z 

2 

Encephalitis aente 
Deaths 

6j 

I 

I ^ — 

— 

z 

— 

1 

L 

— 

Erysipelas 

Dcalh) 



1 10 


_ 

38 

: to 

4 

lorccloe cnicrilis or 
diarrhoea under 

2 years 

Deaths 



ibI 

1 

10 

23 

, 


18 

3 


Measles* 

Dcaihst^ 

I4 223!i53-1] 
~ 1 

.35 

157 

2 

100 

1 793 

34 

37 

57 

136 

Ophthalmia neona 
torum 

Death) 


12 


1 

31 

- 

8 

- 


Paratyplt^'id ferer 
Deaths 


3(fl) 


' — 

8 

I 

— 

' — 

1 — 

Pneumonia inflaen 
sal 

Death) (from in 
fiuenra) 

f84 36 

33] 2 

19 

6 


10 

676 

-41 

38 

5 

15 

i 

1 

4 

: 

Pneumopia primary 
Desth) 

:s3{ S'! 

, . 72 ! 

U 

t 

21 

25* 

40 

1 390, 33 

i 1 

tt 

Poliom>elitJS acute 
DcaihsI 

1071 s 

( 

:i1 

1 

93 

6 

III 

l| 

1 1 

1 

Puerperal fever 
Death) 



7 

1 


1 

-1 

J 1 


Puerperal pyrexiaJ! 
Deaths 

6f 

3 

Q 


— 

"3 


1 ’1 

1 ‘ 

3 

Relanting fever 
Death) 

— 

— 




— 

1 ” 



— 

Xcaflel fev-tr ' 

I>calhst 


lOt 

*01 


37 

* 9*9| 

1 


r? 

2-6 

Smallpot 

Death) 

I 1^49 

I- 

I- 


Z 

— 1 


— 1 

1::: 

z 

r>'phi.iJ fever 

Deaths 

— ‘ 

1 = 

— — 

— 

— 


— 

1_= 


TjThus feser 

Death) 

— 

' 1 ' ~ 

— 

i- 


j- 

i= 

i 

VV> v>'' *g<o' gh 
n aihs 

1 4^3 <*V ( 3 

1 0 i' — — _ 

I 9«4, 3*. 6^ 26* *X 

Oca h)(0 ! jear) 

1 n ' 

.SI 

1 VO 44 II 

Deaths (estlu'* rg 
s jl hmht) 
A*n«al tS a h rate 
(per 1 COD per 
Si nt li ng) 

‘ I 1 

-* 9 i r 

i ',>J i 

5fO 

S7S 

t 1 1 

: 679| IX*j 144 

jt4jil<, 

IJsT h 

Ar— -al rate per’ 

1 O"'? persons 
1. -c 

1 « 4V I(» f. 1 

! i 

1" 

6*JI 

IC^ 5*^1 *4i IV6 

Mi' 

1 ii'3 14 1, 

V 1 

Ra t p- 1 tV.3 
to «l Sn'* («•' 

Ct i “ St ’ 

1 rj - 

1 

V t 

ij 1 

* Z- 

'Mi 


• Mr* i-s ii •A n-’Sj I t 13 Vur a-J i^r re -m» art -y-x as 


t"**~r* '•'* 'T' or 

♦ Dra H Irvvn r-t-a r* a“- *-a-*^<t fr'Tf f C a-d W- -v. 

(a-***^ * nr ere.- I ■•i Ir 1 bp 

1-1 a V f ~ I - a - VV a •*. - — e 

COST- 1 a-'- N-n a— 5 W 1-- 

f rse • -“V c* <1** f"*^ •' » a-- f» ■‘-e-cf- ^ tj for to— 

Ur a-d VV t\ s, L'T'-f ii-"c -» * ^ a r c»->^ o-\. 

I l-v. ^ • pof-rc-il -’t f L i VV » rt a-r Ft 

» p-ura-T pirors'C a CK? t*“f- 3- »*- r « t^e 


Any Questions? 


Corrr^ponJi’nfj should pne ihnr i arocs and aidrcs^cs (not 
for puhUcation) and tr elude all rclexaft detaih in their 
questions i\hich should he t\ped Hr publish here a selec^ 
/ion of those questions and arsiicrs y\hteh seem to he of 
f,cncral interest 

Alcohol after Head Injiin 

Q — Hoi\ soon IS it rd\tsahlc to resume moderate drinkinp 
after head in/»r> ^ 

A — DnnI ing rm) be hirmful to a piticnt who hav had 
a head injiir> in two wajs (1) In ckcs of open vktill 
fracture with penetration of the cerebrum post inumilic 
cpilcps> ma> appear as a complication If it doev hciv'> 
consumption of beer b> causing h>dralion may prcctpi 
titc fits (2) A piticnt who has sustained a severe and 
diffuse injury to the bnin followed b> a long period of 
unconsciousness will often exhibit such svmptoms as 
disturbance of memory power of conccntntion or 
mood In the presence of such symptoms drinking of 
spirits IS best avoided finally anything likely to pro 
ducc headache m a patient with this symptom should be 
avoided This in itself indicates care in the matter nf 
alcoholic intake 

Treatment of Malignant Hypertension 

Q — A man of 55 \Mth lonq standinf* hypertension (UP 
246 150) had a stroke three months oeo from h/jic/i hr 
rccoicrcd one month ago he anokc >u//i a paresis of the 
left leg which rapidly impro\ed but 12 hour^ later he 
suddenly lost the sight of both e\cs rxaminatton showed 
pallor of the retinae and constriction of the arteries and 
there was loss of peripheral viwon objects and colours 
could howt\cr be distinguished with diOicidt\ S’ow (one 
month later) there is slight impro\emcnt in \tswn the 
retinae arc less pale and the disks appear normal hot 
are the diagnoMs treatment and prognosis ^ H ould hexa 
methonuun hromijc or venesection be of \alue in this case ’ 

V — This man appears to be suffering from malignant 
hypertension with episodes of severe vascular spasm He 
should improve v\ith rest in bed a low sodium diet and 
hcxamelhonium bromide Venesection should not be under 
taken because it would do no lasting good and mirht well 
prove dangerous In these cases the patient should be 
thoroughly examined first partictilarly with rcgird to 
cardiac and renal function The effect of sedation should 
then be ascertained Hcxamcthonium bromide may th'‘n 
be administered subcutan'^ously or intramtiscularlv in an 
initial dose of 20 mg preferably with the patient in the 
propped up position in bed A fall in blood pressure may 
cause dizziness but this can be promptly overcome by 
removing one or two pillo vs or if necessary by laying 
the patient flat TIic second dose may be increa cd or 
reduced according to the initial respons- Injections may 
then be given twice daily \s soon as satisfactory con 
irol IS obtained hcxamcthonium broraid- mav N- given by 
mot ih up to a maximum of about 1 g three lirn'*s a dav 

\oie — In reply to a question on the imm diatc treat 
ment of an att-ck of hypertensive creephatopathy t Anv 
Oj'*^*mns ’’ Novcnb'T 2^ 19^0 p 12 j^) the intravcrou 
adrain s ration over a period of two minutes of p'^nia 
raeihonium iodide or b'*xame ho**iun iodide n dos'-s of 
•^0 me w-as rc-omm‘“nd d The irj'‘c ion should be given 
With ib^ p^ c-* propp-d up the ons-t di/jurcss is a 
mral to s op th" mj-ction and to Ia\ the p-ticnt fl-t 
b^caus*- th s means i^^t a s^tisLe'o'v fall of blafjd p ^ u •• 
b-s b-^-n o'" ain-'d a^d tb* full do * is and 

m^v p ovosc too s*ae c a rcac cn Th* b-iam* brniu'*' 
co^pou^ds <hoj d no be erven I ~^Jh in r-n-raf p _r*r*c 
lb* r su ccssful ad'Tm s ration requ nrg co" d*^ 2 b * Inow 
ledge a-d cxpc*’*^cc ^ 



50 Jan 6, 1951 


ANV OUES'JIONS? 


Vrr>*CAi 


Intriplciirnl I* \.S 

0 — //(It iiirri I’lciiral run iiniliianilu \hi t cUt (I'iJi} 
Inn Ineil in ilm iniilnrni of rtttnun nr\ uiheniilos 
If III nllh u/in/ rfuitis’’ 

A — Soliillonn t'f ji r.i iiliini'filiLyliv itij lu\c t ccn ii cil 
LMciiNtcIt in llic Ircilmcnl of ml 'tiiilmn cmp,ct>in 
I’ A S fi iitcn itiiripkiir ilh iimiiII) in Ilic fo in ( f n CIO 
■lOltKion of (lie «(' liiim till 5(1 to *.0 ml l>'in micvicti 
'\ccl,l> nccorilmj to III* ^cicnls of lli- ntc the icnilit 
ire ^ irnhle nnJ dcpriul on the ilc tee of tlimcriHj of the 
plciin inJ the (.liioninn of the Umoo the proc iir of t 
hroiKliopIcii 'll fotiili ililioiji not m nt tot ne coin 
indmlion ivill li tc i icnoiii ml cite cllcil on tf r 
ircTimc It 

To ohi in the hett rcMill« ill put iiuiti l-c ntpinlcd fion 
the plciinl civin nni! tin ti nj m lOnn! out «ilh tinriinl 
sniine I cforc the injection of the I’ A N inlntu n In cit-t 
with <;c^ont!ir> mfcciion lint ilioiiM Ic ircTir 1 «iih p-n il 
lin I cfo c ti'ini P \ S I o il ancilhc'i t lonlainni pm 
aminol’-niou ncid thmiM not le ii -J tuih PAS at 
ri rn iminol cn/n 1 . niul intmomuct P \ S 

In tint coiinlit the noil fitoiitiMe rctiili' tine I 'cn 
recorded In 1 Ci Diinptet ind M It I oj ■■ (/ onrer 19-!” 
; f.7t Inhfrc’r 29 2If) 

\ I) Proplij Inilt 

() ~ II / ( I (ire thf lei! i ei. suet of leisii t /ropiitf to 
Ilf an II senereni iliiei n ’ 

\ — \ condo n ttrcftillt put on md cmcfiilh icmtncJ 
will nlniotl (.ctnmK ptetenl infection o' ll c partt cotcfvd 
hilt not of coiit'c of the tiitronndint tl in 

Ilinrotnh mvliirii of lie \ hole renml nei t ilh toip 
md niter followed h) the ippik ition of cilomel cttim 
(tonlainini n tiilplionatnid* o'- mcrciirj o\>k) miJ 1 "ill 
prevent infection m the \it| nn|oritt of ckc if c irried 
out mime Inlelt nfier ctp'tiire 

Pcnicil'm nhlel fipOCKH) tini t) tmliowed within i few 
holirt of etipoMire nre tud to pretent inftclion in t Inili 
proportion of cites 

Siilplndn'ine one or two ( r imnut t ihen it once follow e I 
b> 1 timihr dote nett niornmt it hliK to pietcnt the 
detclopmenl of (onorrlioei Init not of sjphlht 

A few ciptiilet of lureoiiicin cich of 2'0 it t twni 
lowed soon -iflcr c\poturc will pioh-il !> pretent infection 
With either i onorrhoen or ttphili hiil few intctlnitions 
with this mlihiolic lute >ct been reported 

It will be clcir from the foretomi lint the sooner and 
more thorontlil) proph>l-i\it it ipphid the Kreitcr will he 
the clnncet of pretenimp the detclopmenl of infection 


Amplicl imliiL nnd Ciirdhc Arrhtllinilii 
Q — Is ainplulamlni likils lo linl In niiruiilttr fihnlla 
non in a healiliV person or in a person n/io siiPert from 
mitral stenosis of rlicnmaiic oriiin iinil has a histors of 
St sera! hpiils of eniri<iiliir fihrlllalloii ' 

A — Amphct-iminc is unlikely to Ic ul lo 'iiiriciihr fibrilli 
lion in 1 hc-ilth) person But on the whole it it wise not 
lo use such drugs for pilients who lute i tendency lo 
c-irdnc irrhythmiis md cert only not for one who siiflers 
from milr-il stenosis nnd who Ins hid seterni bouts of 
pnroxysmni nuricuhr fibrill ition 


Lupus I ryllicmntosiis 

Q — B''/inr ts kiionn of tin aetiology of lupus erythinnt 
tosust M hat ts the trcatnuni of tin acute ihisernma/i il 
and the chronic localized larielies respeciiicls ’ 

A — Chronic nnd acute lupus erytlicmnlosiis nre thought 
by most 'authorities to be rclntcd nnd occnsionnily the one 
IS seen to pnss into the other though more often the types 
retain their identity throughout their course Their lelio 
logy IS unknown but is nssoci itcd with i dislurbnnce of 


MS tilir fiinctinn nnd sometimes lo the ndjiisiment of this 
ti> elm itie conditions locil sepsis drug therap, and 
sometimes other disorders nny net ns predisposing factors 
I iiipiricnl trcitm-rt with gold injection is nl present ih- 
iiii'l h'lp'ul iii'isiirc In lie ii inngemcnt of the eh oni 
form of hipi s crylh'-iitilosi i 
In 111'- SCI le typ- ndre uKOiticolropic hornone (A C T 11 ) 
nnd coiii one piudute drnii’ilic resi Its but lie d sease 
rflii ns ns b ills ns eser on their wrthdrnwal Some ens'- 
hise n >w b-en rep ttc 1 m whrh prolo-iged adminiitral o" 
of the ' sul linrces has inn n! lin'd iinprovcmcnt In so-nt 
cn'cs ihi 1 ip oscni'nl has Insicd for periods of mo'dis 
iftcr III' cc sit on of ihcripy 

Clirmilc Otitis ! nlrma 

(} — A f,lrl I f 2 1 1 1 s t ^ I ^'i rn * 1 1 nirii o'lii? extern 
for IS 1 o I r 7/ e (O' IttI ' I e i 1 1 r ser es of hi dr it 

tie et e 1 < i r nn j ' hi p oied rex i! r to ortioJot 

lie I net II / ( Ire n ter' i su 

k It s mil I 1 ' \ ' ih iryi", i riehatn n cill 'r bs a rasi 
lie ap, op'in'e (h> - I'uig dc errm"'(l I") n radie'lciri'l or 
by tl " local nppli^a ion o' an a’ci hohe suhition or satn s’ 
lO itanng I'm it m \ 

t lc.lil hcailcdness In I Iderly Diabetic 
<) — A hile'or I e ' 72 ul h i. o I’d dee ee of t't^' elei 
iieliitiitioi ro'le' hs diet et p'l u of r ten ton of hel 
lo le *resi it' eh 'tv tdter cn 1 1 to t I tl e I oh eh e ers 
I irr Ir tier I le !sf i 7 h'l pen tij for It o or thee 
/ '(( i lilt hos I preit ire It < ’> j/d ,* '! r tied He cht 

supers ft"! 111,11 of ePi 't III h tl i e use of tin 

lensalu'i i - 1 ii tl rre i s tree o 'i l 
A It ' s pro’ nil- thni t'u< s,np.im is rcl. 'd to 
irttsicn dis'url'-ince of tl - cc c’ t! circuh icn poMicti 
Itrl) ns the presen c o' ipginn irdi-ntrs nrtcri 'c'cros s 
It IS nt'sisable lo eosu e tint d 'lecitmn should be as 
ncitls clforlless ns pisutlle ml ti' this end Iniuid pnraflir 
si oiild 1“ p es-iilv: I to I cep 11 inl-'linal conicrts soft 
If p 'ss hie the pnticnt should hreilf-is| 1 fore 1' Ins 
dressed tnd nfter tic K'wels hasc Ken evacuated he 
should letiirn to led for mim"rs On first wakir!. 

he s’l iilJ like ) ir'ft; me) o' phcoobirbitone 

Sitrllirjilon of Syringes 

(J — tl hi intlseftit I ilsc I le tti I oil ct dl he resom 
iiieiule I lot It hliitr to the liil ritit it of i i irlecltor ssrt tee ' 
II I at loieeilrnnon st mil I le leiess n to piirrai It e ll t 
slerdllt of the ssti le’ 

A — It IS impos iblc to sieiihzc i ssriii,!' by this method 
rsen rerrmcides m solution m w tier dr not penetrntc the 
crevices nnd ill cheiiiici! mc'hods f sterilizing synnees 
hnse been found inelTcclisc Obvn isls nrens not reached 
hy in nt|Ucous solution would .’p, even more imcccs ihic 
l(> 1 siscoiis oil I uhric ition nnd sierihziiion (hy drs bent 
or ititocl ising) slioiild be sepinlc processes Tull insirus 
lions md subsi mlinlion of the siitsincnis nude will be 
fcrimd m rhe Sterilunlipu Use and Cere of VimicirfMcdi 
c-il Kcscirch Council Wir Mcinorindum Ko I*- HM 
SI ilioncry Oflice 1945) 


Afl commimJcuMon* >>iih rcgtril to editorial btninc'^ AhoiiUJ be add c<tcu 
tl Thf IDITOK Hmtisu Mri'K al Joit'su ll M \ Holai TaMMKTc 
S qtiAur LoM'OS \V C I Ttirrnnsr I USTON .111 *^**^**'’?_ 

^nl <»e> 11 ejfrenf Lvnltn OI 1G!''I M APTlCll^ AND LCTIERS 
forwTTilcd (or uUlealion nre im Icruood to I'c ofTcreJ to the British 
\trticat Jtttnal ftlone nnlc^t the contrnr> be stated 

Miihirs dc frne UMRINIS ihnild commiinl aie with the Publi hins 
Mnmeer IIMA House Tft\lsiock Sotiarc \\ C 1 on tceeipt o( rn'ofs 
Author* OAcrsrti sh nild Indicate on MSi (f reprints are required as 
proofs are not s ni ahrmd 

Mn C RTISI MFNTS sluMild be addressed to the Adveftiscracnt MantRcr 
IJ M \ Hoic TcivIstxK Square London \N C I (hours 9 am to 
pm) IrLieiuNc FUST ON '’111 IriroRAM^ BrlimeJaih 
M ejrrenr Lmdon 

MfMIURS SUI SCRII TIONS should be serft to the SI CRIT SR’V of the 
A«ochtlon TiLrrtiosr LUMON -111 DiCQaAVis htedlsfcr,} 
11 eslcfnl Loriil m 

n MJV Scomsii Omcr 7 Driiimhciifih Gardens Tdlnbursh 



LONDON SATURDAY IVNUARA 13 1951 


A FURTHER STUD-i OF THE TEETH OE 5-YEAR-OLD CHILDREN IN 
RESIDENTIAL HOMES AND DAY SCHOOLS 

m 

MAY ^tCLLA^n^ 
tso 

nniN MciLANn^, md, rito 

«illi lire A«Mnncc of JO JO\ MZR, nnd M \I!ION Mril\ 


It was brouj^ht home to one of us in 1929 when cxinnn 
inp the tecih of some *' \eiroId children in London 
Couni) Council schools that there was a grcal differ- 
ence between the condition of their teeth and those of 
children lising in orphanages in the Midlands Among 
thcLCC pupils It this time there were onh 4 7S-j*'Mth 
caries free or almost ciricsfrcc deciduous dentitions 
whereas it was obsious at a glance that the number of 
orphanage children with caries free teeth was much 
higher In 1944 the chance arose of maling a limited 
number of sastcmalic inspections of the teeth of children 
Using under different conditions It ss as decided in the 
first pi ICC to see whether ans changes had occurred in 
the teeth of L C C pupils bctsscen 1929 and 1943 The 
improsement was so great (the 4 7f; of 1929 had 
increased to 24 29 in 1943) that similar inspections sscrc 
made in 1945, 1947 and 1949 (Mcllanbs andCoiimouIos 
1944 I94f> Mcllanbs and Mcllanbs 19-,'! 1950) 

It was not until 1945 that an opportunits arose of 
seeing sshether there was an> real connexion bctsscen 
Using conditions and dental health in orphanage and 
LCC children Concsirrcntls a similar inquirj ssas 
made among pupils Tiicnding prmte (fccp^iing) day 
schools lilc the I CC children thej Used ssath their 
ossn families Mcjnsshilc sarious ssorl ers had obsersed 
a tcndcnc> for children brought up in orphanages to 
suffer little from canes sshilc others including Collett 
(l‘)tS) and Sielmitr (I9i9) in Norw is and \ndcrson 
el a! (19’4I in Toronto had published a fess figures 
relating to mixed age groups indicating that there ssas 
less canes among such children than among the general 
population The threefold surscs of 1945 (Coumoulos 
and Mcllanbs 1947) shossed that children Using n 
homes had the ssorst dental s'nictu c suggesting poo 
cikilsing diets during tooth dcsclopment and set had 
the l-ast ct ICS — less than the children of comparatiscls 
Well to-do families and much less than the LCC group 
It sssu'd base b^cn instructisc bad ssc bs-cn ab’c to 
paralM esers si-xes in LCC schools ssith s milar 
insp'vtion an on- residen lal homes and p is i e school 
shi'd cn bit Ih s w„s nst passible Ear's in 19'0 
howese t’ e tsso g oi ps n question we c 'cirsestma cd 
T! IS se-nied c p-^ialls u j sue tb- p es*rt po! ex 
o' bsirdi"'o • .-J sdisp on is 'cmosj-- r--si's a’l 
' S sS ds ' o- 1 o— ir’S 

In s pap- v.-acus"" h" tc"a " t-o-’- o" 'r«i 
dr- lbs-- to esse res d — lal --.-s- rs and s x-a-Is 
admi- s e cd * s t’ - S - e o ‘■s so -'.-s s-as j, j. 
s s s s ssc ea' -d -' It 1 a-s 7b-s - a e r" - i-ej 



for children deprised of a normal home life for i sarisis 
of reisons su-h as the death prolontcd illness or p ison 
sentence of one or both pircnts illcgilimac> or lack 
of suitable housing f icililics Pormcrlv such children 
sscrc accommoditcd in orphanages or insiitutinns of 
sarious tspes including ssorkhouscs 

Oinical Material nnd Mcliiods 

So far as possible the same homes and schools sscrc 
included in the 1950 sursej as prcsiously but others 
from near bs districts sscrc added to increase the size 
of the sample In all 45 homes fmiinls situated in 
I ondon and the surrounding countr> ssith a few m the 
Midlands) and 32 prisatc ind jndependent schools ()n 
I ondon and adjacent counties) sscrc sisilcd the total 
numbers of children dcntalls inspected being 542 in the 
former and 560 in the laficr group In 1950 as in 1945 
the aserage age of both groups of children ss is jpproxi 
matcis 51 scars 

Tlic standards adopted for hspoplasu and carles m 
the clinical examination and the methods used in cal 
culating the results sscrc the same is those tmplojcd 
on mans presious occasions The degree of h>pop'asia 
ssas estimated ssith a right angled probe and the 
rougher the labio buccal surfaces the greater the degree 
of M hspop'isia for diagnosing canes an illuminated 
mirror and sharp rat tailed denial explorer of standard 
size sscrc used The teeth were neither dri-d nor 
X rased since although these aids to detection ssoild 
hasc rcsu'tcd in more canes b-ing sc-n the fmdinjS 
ssould not base been comparable ssith tho - of p-st 
sursexs morcoscr the diagnosis of ll c p gs-n-c «nd 
extent of cincs bs ans kno sn m-ihod o'tei come- in for 
ciiticum Tor this isp. of ssor) the irnpo tint thing is 
to h-sc arreem-nt on the ' andards to be dop cJ fo! 
losed bs ad' ercrcc to th-'c s andards on trie part of 
the inscstiga o s ssho must wo i m close cod bo ation 

Thcm-lhoJ of p c eating lb- firJ ngs csp-.nlls those 
rclatm- to ea i-s is also op-n to c ti-i'-n V. c base 
con dered the irgu-ncr's for -rd -g-'n j f,ur 'em 
a-d t*-- sch-r--s adogtc! b> 'ime o’b- *o 1 ers bat 
fp sarious rc_son ac p e'er to re a n cu oan 'Iml 
den -I rese- eh ssolcrs co-cc-' -Ic r-- n's on t* - 
i-c 'cnee of di'eas; m-' Ji- c idi.- - o' p t'-ca in 
cco J t*-- d— tal s _ s of a- g -n g o p o' 'b- 

piag tion Tl's o'ten ico c t' c s rt i - o' t'"- 

icc h api • f OTi I*-- g o's- 'o ns o' d-f-cl and d' 
b-a-i'g o- t*’- I _b ' s to o le- Vc bnac e- f-- 1 
s’ron- iSst b's ’ sS-oj 1 t- co- 2- ci a-d t- t i- 
_-co d.—e with ‘"e p c.ep s o' p esc- c —-dr -r |- 
c“pha' s '’ou J oe c- t'"- w- <_ c f-d --d ea c"- 

4697 


52 J\N 1^1951 III 111 O! 5 'll AK 01 D (Jill DKI \ 


frjTin 

*>tir ^*L )oc> ui 


fat Ictlh rillitr III in nicrcli on the incnlencc of dcfitt 
or di<;t isL In iisint Hit rcMil|<; of the Mir\c\\ there 
fort \Nt mintion hrst the more ideil >.tiic whith il 
K liop d mote tliildan will u'liniiteh HI iin 

In iv^vssmi the iiiiihlt of llic Kelli dniMon w is nndt 
into those iiliich wtrt cstcrnillj smooth (no hspoplisnl 
ind those Kith \ ii\in[ dej acs ol r ' i, h i s of lia I ih d 
or biitcil stirficts Mhspnplisii (Kinp l‘>:Oi v\ is 
grided M 1I\, to M lU, utoidiiie to the incti isini 
scscriis of the defcvts uhilc teeth Kith ceriini kcII 
dehnid tips of siirficc irret ill itits vttc is helots 
chssilicd sspii ittls IS i ross or tcslhoo'. hspoplisii 
Ihe niinihtrs of lesth in the sirioiis citeponr of h/po 
plisii ire tspres sd in tlie t ihles ts p-tsmi o ' of the 
toll) iuinibi.r of teeth c\ imiiicd An\ teeth kIiicIi 'sere 
so cirioii or hid siish heiss deposits of tirtir tint the 
siirficc structure toiild not he j iii ed sssre omitted f'o ii 
this tl issilit. ition ind tlius from the I ihles dcihiu s ith 
‘triictiirs Ills iseriee sstsiit of sii f ice tevtiia cKfest 
ol the M Ivpe 1 rep e cut d In the isersi hspoplisn 
fi tits (A H I ) this in conjunction Kith the p ten 
lijss of lupoplislit Icsih IS Kc h hese u efid m 
issessiru tla improscmcnt or othttssi c in Ih- dcitd 
stnicliirc of Misses nc simp’c o' chihlreti -for 
cMinple 5\ti'’o'd I CC pupils es iniincd hetKceii 
ion ind 191') 

Cirits IS LSprts ed both is mtidents ind n cslent for 
cich tsp' of tooth ind for the sum of ill tsp.s m 
cich group of children Ihe incidence of dec is In 
itstif Khsihcr given is i psrccnti'e or iis the D I 
(dtci)td rnis'-inj mil filkd) In me i m lie rniste idinr 
since i group of individiiils with snnil civilies wonld 
ipp'ir in the tih'e to hive the sitnc imniint of tines 
IS 1 iroup in whieli the civitit vvert hree lot this 
rt ison tilt estent of cities m cich dctivcd tooth is 
dcscrib''d is heinj of tr>tlt I 2 or 1 icto dm, to tic 
cstim ittd si/c of the civitj in rclilion to iht sire Oi the 
tooth Iht ivcric. ciries fij urc (A Cl ' hie the 
Alir IS some Inttion of 1 ind me isu s th- csti 
mittd ivcngc estent of cants in the ictlh In our 
opinion the idv ml ire of this method ns ii iinst those 
involving tooth iiirf ices is its rehlivc smiplitilv ilso 
the results so expressed nrc compirihlc with those 
prtviouslj given m this scries of aports mil thos- pub 
Iislicd by others using the s imc mtlliod (Devet ill 19)6 
Divics 1939 King 1910 Coiimoiiloi 1916 Stones 
cr al 1949) 

In ill the surveys mide since 1913 it Ins lacn possible 
to cilcii! itt from the pubhshtd lij iircs the 19 M 1' 
vilues for uislmte the pcrccntirt of eirious teeth 
IS expressed in T iblt IV and in c irhcr p ip^rs is cqui 
viicnt to the D M r per 100 deciduous teeth vvhtlt Ih 
loiil number of cirious Ittlh divided In tht luiinbir 
of children ind then multiplied b, 100 gives Iht 19 M T 
per 100 children Since the deciduous incisors arc in 
process of being hed between the iges of 5 ind 6 years 
the missing ones ire considered in ill our surveys to 
have been lost natiin'ly ind ire therefort omitted from 
the tables On the other h ind inv ibstnt c mines and 
molars would ilmost tcrtiinly hive been cxtricled for 
canes al this period they ire therefore included m the 
canes totals (grade C3) It will be seen from Table I 
that the mijoiity of missing incisors m this age group 
arc lower centrals m which there is very seldom any 
decay so that the total number of dccivtd teeth which 
might have been present m those counted as shed 
must be small It is obviously more difficult to inalyse 
caries figures for children of mixed age groups espe 


I A*'M I — J ffcrnhi ft tij Fffth I /r rut rt Time of httf tip 


1 

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tidly iho " b tv ecu 7 iiid 1 2 veu hccauvc the times 
of c iipimn and shedding vary wnlclv for the 
3 veito'd tnildicn the I ivl is rclitivcly simp'r From 
I able I It IV iliu seen tint nearly •'ll Ih- tctlli arc still 
m Situ Kith the cvtcption of the lower central incisors 
V hith ate norm ill shed re' tivclv cirl 

Res lilts 

I ibl- II shows the p tcniiges of chi'drcn in the 
IV iv proiipt who were tines free and those who were 
icirlv so 101 ether wuli the mimbe s of D M I teeth 
p r 100 children 

Tv I II -n 'tfr fi I t r If A!" I S > a f dr D Vf f 
I . ’ ri /r /( 1 (/ ( r Af ' 1 Ih ft II II ) -nl 


/ ffi 

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1 rrs 



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Mllioiiih the Inures for tines free children ire given 
Irre to conlorm with the reports of all the earlier sur 
vevs of the cries it his ihroual out been rvili/ed thil 
where the dilfcrcntis btlwccn the vinous groups under 
review irt not spivlitiilir a betttr picture is giincd bv 
tonsidennp teeth r ithcr thin dentitions Ihus some 
10 more priv itv school thiUlnn had dental dccav in 
1950 yet the told p-rccnt it c of tines free /< tJi (Co) was 
ittii illy grciltr than in 1945 In other words the 
disc ISC w IS port vvidtsp cid at the lime of the later 
survey hi t vv is of 1 milder form (sec I iblcs II and IV) 
Ihe findings rtliting to Iht teeth as opposed to th- 
whole dentitions of the children irt iivtn m Tables III 
to VI In tonsidcring them, a comparison will first be 
inidc belwetn Ilit 1950 and the 1915 results for each 
of lilt two groups of children sep irately Then the 
rtsulls for tht rtsideiitiil homes ind the private school 
groups will be tompircd I’issing reftrcnecs to the 
findings mice schools in 1949 ind 1945 will also be 
mailt although tht interval between cxaminat on was 
SIX months less for Ihcm than for the other groups 

Surface Slructurc of (he Teeth 
RcsKhnttnl Homes iii 19'iO amt 1945 — It will be seen 
from Table III (toliimn 4) tint 42 Cf, of all the teeth 
were perfect or nearlv pci feet in structure — that is 
hypoplasia free — m 1950 is compared with 32 3% m 
1945 This improvement was found in all types except 
the uiiper first molars, which remained the same as 
before and tht upper second mohrs where the 



Jan 13 195! 


U nil 01 5 "VCXH OI O CHiI DIU N 


ptfccnl ire ciccrca'-i.d Ml is rcTlirci' Int tirlirdcpo its 
found on i proparlion of i ppc' niohrs cspcc iii 
second molars ma> m isi tin. ‘^ti-l surfa^^ tcsturc 
thus mailing it dilhcuit to jss.'ss th. ructurs and th-re 
fo s an\ change Pus applus to all our su css ) The <. 
ssas scr\ little M hspopi sn of 'I - most scscre grade 
(M Us,) in ans l\p; of tooth in I'Pfl less tinn P of 
ill the teeth examined fillin" into this categorx s 
compared ssiih the shrhtK hi li'-i fi urc of 1 7'' m lOd*! 

I he Alir had dccrc sed fo esc \ Isp- of tooth 
except apparsntls the iipp'-r s'-'oad molars the told 
basing fallen from 093 to 076 Gross hjpop'asii 
though rclauscis loss in huh cues was losscr in 


l‘P1 th n p esn 1 I 17 of all te h •’s c 'ipircd 
with 4 b in l'>..s b i"_ a ’sviss' Is this f s "i of 
dc'^ect 

f'r i, € S / ir t !“ I t ’ ‘ ^ — \ 1 s ig thes" 

children d e dentil stn cti c s is ib u t a Is lu- nu 

n lO'O as in the c rlie' sms s Ihc s sss l ^3 ’ of 

tiL toial tscth f -s Iron) hspaptis a as soupar d s itl 
“stO p ss ousis n d 'l hi colum 1 4t Soi e s ch is 
the iipp - in..i o s ind can re h ass d imp oscit cn> a 
the fisc seir p-rii’d ishi'e o he s n ata! is the n o ir 
ssc c not a good as fomi'rls 

\s in the cue of the is ids i lal honvs sers fes' 
tecti had rsalls seserc siruclurd d'-‘'s‘-ts I'l Hs ' ll s 


Tsri r III -Conir nn nf 1 oo I ^ rncturr tn Krsiilr tit 1 Ht r\ iR U t rr ^ Prttrtf Sc} 




I 


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ACI 



54 Jas 13. 1951 


H LIII 01 5'iL\R 01 n CHIIDRI N 


Miirfii Jon/txAi. 


proportion btinp 0 1 of all the icctli c\ imintil tom 
pirctl With I 2 j in 1945 Hit onl) ivelh comint within 
this tridc 111 the more recent sur\c> wert tht niohts 
There w is vcr> hlllc sariition in the All! for the 
ihlfcrent tjpes 'itui the fieurcs for ill ivpes to; tilicr wen. 
thcsime Gross h>popl isi 1 w IS ipin \et> iintommon 
in tithtr jt ir the tiinl imoimt in 1950 hcini (1 1' of till 
tcLtli cs-imiiictl--l less tlnh in 1955 

Coniptiri\oii <)/ //i«ii( r aiul VmtUt Si/iKilr—lt still 
be sun from I ible III tint thcchiUlrcn in Ih’' tisiilcntnl 
homes in 1950 still fml worse dent il striKtorc th nt iho c 
in the pris iie jthools 5}. 0'^ of all teeth as compared 
ssith 17 1", shossmt' sonic depice of hspophsn (A 11 1 
0 76 IS ipitnst 0 59) Since, hossescr in the former 
group thirc Ind been in impiosemenl dntmt the pist 
fisc scars—ilnt is the pcrtcnlipc of htpop’istic teeth 
hid fillcn from 67 7 to 'SO i I4‘ reduction stliercts 
m the litter troop there hut b-cn none the dispstitt 
t\ is kss 

ICC Sfliiuilt — \tnoni the I C C group examined 
in 19 59, ilthoiiph the peiccntafe of lispop! isiie teeth 
had mere ised soniesth It since 19 '5 b*ine 6Mp iiscom 
pared with 62 0 the A II I w is much the same 0 5x 
compircd with 0 91 

As rcpards dent il structure therefore these ohstrsn 
ttons indic ilc i jcncral improscnicnt an ori) the tesidcn 
tial homes pnpu! ition since 19*5 but hlilc chain c imon 
prt\ lie schoo's or the 1 C C i roup I he pris ilc school 
children hid on each occision the best formed teeth 
svhilt the positions of the other two ( roups were resersed 
nt the time of the second insp-ction the rcMdcntial 
homes proiip his ini heller t deified teeth linn the 1 CC 
group though not re ichinp the si ind ird of the pris itc 
school children 


Carles of the 1 telli 

In iiiliniiiil //on ei in 1‘J^O and /'-'/S — labk IV 
(column I) shows thit in spite of 11 c f ict that a larpe 
pcrciiiiitc of the teeth were cants free in 1945, there 
w IS in impioscmcnt darinp the live jears hetveen in 
sj'cclions the tcspsclisc hi tires b'ln; K9 5 and 92J? ^ 
of the lo'd mimlvr ex mimed This improicmcnt was 
icflrcicd m each i)pc of tomb but esp-eiilU in the 
molars, md in pirliciilar in the tipp-r moLrs With 
re, atd to discisc incidence there were ser> few carious 
teeth in I’l'-s'' rcsidcnii i! home children m 1950 ,onl) 
7 2 of the total number h*inp alfcctn! a? compared 
with the p csioiis II) lire of 10 5 which was in mH) 
CISC scr> low In pissinp it mis Ic noted how small 
ss IS the p opafiio'i of carious teeth praded C remem 
berm tint this catcror> inch des exir iclions The extent 
of cities IS exp cs‘ed h/ the *5 C 1 fell in 1950 fo 
cvets indindiiil tape of tooth the hpiirc fo’’ all tjpes 
(oi ether bcin- P 12 as compared with 0 19 m 194' 

/•/mite Vi ltni>h ri! /9'0 1 1 d /9.‘5 — The p is at school 
children showed a slijht improsenent m the fnejear 
inters if I he total percent ige of canes free teeth rose 
from 65 s I,, s 7 a and rich isp* with ih- exception of 
the towe' ic ond molars shoscil imp osement The 
pc cciitipes of carious tcc'h at the l so inspections were 
thus It2 in 19:5 ntul |2 7 m I9<0 Ihc \cr fo 
cich t>pe of (oath m 1950 was (he simc as or lone 
thin before so (bit the totil \CI showed a slight 
rcdifction (0 2S to 0 22) 

f ontp rison of Hornet nt I I’nti'e Sdodt — The 
(initcs jisen m I ible 1\ mficitc that ns m 194' 
the teeth of the residcntid home eh Mren ixnmmed in 
1950 still hid less discise linn those of the pris ate 


Icmi \ It n !i I te I’f Ciinet in Terili tilth i On 'n of Stitnlii'e 


Olhiiuti I (SlCa-n 1 I 1" 1 'AO (tl Mlaiivs 


(t) Cfailc «>f 
Sfn/ tufc 

* 1 
• (*•) 

1 Group I 

l t>l f n , 
1 1 


S'/* j 

1 af j 

1 1 »4i n'\ sJ 

<. Jfi 

.. 1 

r ^ 

i } fj j 

f 

T< */S< 

1 tin itf ! 

j CirlMT 


1 ! 

i^45 

im } 

/ JI3 

j 

U44 

] 


15* \n 

i 4i 

*3 


J9n 

1>I5 

liso j 

i fV43 



1 K II 1 

1 7n 


<1 4 

< i : 

<(»{ 

t 4 j 

0«l 

<7 3 

5 > 


0 4 

S 1 

O'M 

4 1<I ! 

1 03 

1' 


' VS 

i » 1» 

' \4-» 

(1 *5 

f 4 1 

f <171 

1 SI 1 

0 ^ 

l>6 


f 

)0 

ro 

5 W 


1 ! ' 



t H If 


1 IM ' 

7 

< 7 1 

(yf) 

hM 1 

' 1 

I 4 

5)«f 

- o f 

K t 

J” f 

4 

\«Ol 

; 4 5 


(M III I 

15 

4.1 

^4| 

y H 

H ? 1 

J«d 

437 1 

f 4 

1 i 

im 

“ *57 , 

Of 

t 

' ll<3 


1 

i 3 

Pefccfifc Hv ) K n ‘ 


2/1 ) 

**/ f 

»4 7 

?> 

f) ! 

U” 1 

i"ih 

' 1 on 

f *03 

t 

ra , 

1 3f5 


i 



1 s ^ 


HI 

{U» 1 

("1 

\/ 

10 { 

1 t's '1 

(io oj 

(■f i 

1 (^75 

»r 4 

J'" 1 


\ 

! "5 



U H 

f3 

4 

pS 4) 

U'b) ■ 

3 

IT 

UUTJ 

^ 1 

; 

77 



107 

•sf 

[ n. 


JM IJr.) 

1 S 

N 

i 

Irsul 


1 

*> 1 

t MMf) 


. '7 

/4 

1 "1 

N A 

i>7 

J4 

1 

{* 9J 


( a ff 


44 I 

n\^] 


4 

i 1 

I mot ' kV(ii 1 

1 

/». 1 

1 f/H 

1 5 


1 

! 

333 


Us 

34 

If 1 

i>h 1 

1 'll 


K 1 

1«>1 

iKl! 

1 ■*'' 

5 I 

1 llsi) 

I'S'CI 



I ti'pi 

t’S 11 

___ 




... 

_ 

— -w— . 

— 


- — 


— 



“ “ 


o(r —rof iomc } rjd 

t of «tru 

(urc (he nu/fib /•» uf (cefh * ere tclit vtf/y muU 

ihcr 

rv niAi- 

1 .nc 1 1 

1 n Ih w 

t hT>rJ*u) M*ni 

CAT C 

»r*3 vf 


ihcrcrorc gi^tn In bnekeu 


Tmui VI 1 1 ( 1(11 of Canetm Teeth ntth I n/im;, Crtnltt of ifriHliire 
{3} lotm f4 I i4JCanliiCT j (5> MtiUfs 


{() VtlThTct 


{/) Grade of 
Struc-turc 

i 

(■’) 1 
C roi»p 

^ 1 

1 XV 

J N ! 

m ) ' 

IMf 

ACl 

' f tfii 
! \ 

)M5 

S 

tncU 

! •'< 

I 

7 111 No 

1 tnminccJ 

! 

r 

1 TtOa) No 

1 tTMi/n d 

\ Cl 



I91< 

i /*() 

1950 

l*)4' 

*7'0 ' 

[ f/45 

P730 1 

1 lias 

l‘>50 

11 

1 >'0 

|9!5 

1950 

Good (Ify ) 

K if 

i 1 ■’<'/ 

2fn3 

1 i> t i 

UlK I 

1 'lb 

1 < 

GOO 

G (8H 

1 *0 

n4 

1 0 0(34 

0 \\ 

i 9 

4 

0 wf 

0-0 

1 

PS 

i m 

3 I4'» 

0 Oi 

0 O'* j 

' 1 «7I 

1 74 7 1 

0 G> 

GOi 

7*8 

fOO 

' OOf 

0-4 i 

1 3^99 

5 <\( 

0 0- 

004 

SHi,ht)> dcfccfjve , 

/{ /{ 

1 SOI 

/ IJ4 

* no4 

O/iV ' 

' r 3«» 

KH j 

0 04 

<»<» 

‘ rv 

G f 

0 u 

0 f j 

■•477 

3 9)} 

0 07 

0/3 

(M Hy ) 

PS 

523 

81! 

i IMS 

0 H 1 

1 3 50 

457 

M \\ 

tMl? 

\ no 

55 

0 Rj 

0 30 1 

;* fb3 

3 h55 

1 0-7 

0 2' 

Dcr«llve(M llv 1 

n H 

1R5 

2lt 

1 0 n 

O 3 


1 


,OW| 1 

; t U'7 

1 50< ( 

0 M 

0 '0 

) \ 315 

J 775 

i 04> 

0 19 


Pb 

145/ 

83 

1 0 

fit nj 1 

^ Jr 

W 1 

' f" /'! 

h wf j 

' rr > 

UUi 1 

/ // 

0 n ' 

9 854 

) JSS 

i 00 

0 57 

Very dcfcciivc 

H )r 

13 

a i 

1 m )| 

[0 -*5} 1 

i 3 

1 

1 /(HKi; 



17 1 

!J O')! 

llUll „ 107 

M 

1 0! 

[oail 


Pb i 

8 

0 1 

;1‘ <t} 

0 oo 1 


"1 

(OtHij 

GOO j 

77 

H f 

!’ laj 

ill 11) '1 S7 

14 

1.07) 

111 !ni 

Gross (G Hy) 

R H 

80 

V, 1 

I'UI) 

10 ni 1 

1 24 

4 ! 

fOlHU 

{ » wi . 

» 77 

~ 1 

0 

0 IK ' 

301 


0 47 

0 IB 




>' 1 

! 1» 7f ) 

! 7 50} j 

i 12 

M 

{0<K)| 

{«<K»| { 

4^ 

5 1 

(Ob6| 

tl -0) ( 

! itb 


10 7<9 

fnas) 


(her^ore gjviTn iifhrackcu^* of'sfnicture tlic numb rs uf (ttdt were rtlitiv ly mhiM Ihc VC* biud >n tlic^c probabty (n\r hdtc siiknifii-Tncc «nt3 nre 



13 1951 




rr LTfi or «: m:\r oi d cnii i)Rr\ 


school cfiiMrcn 72'* in the fo rTT frnup cc'npifcj 
Viilh 12 7 4 in llic liner beinr c i lom Thom h n i o*h 
caici there had been in imp oicmL"! in It c fise \cir' 
Ihii Was proporlionalcli p cite in llic former (i drop 
from 10 5'' to 7^"j of ciriotK t'clh— n reduction of 
720% — compared with n drop from 1-5 2 to 127 
in the priaalc achool proup-a redu^tioi of 10 ‘i ) «o 
th It the pap between the proup h d widened diphtly 
ICC VcAoo/r — tn conlrot to (tie ^Irht in p oaement 
in the aboae mentioned pioiips tlic I9-9 aiiraca o' 
I CC achool-childrcn shoaed no inproacment in the 
canes position as compared aaiih lOaS 'TTi'- proparliona 
of carious teeth in the two jears aacre 20 5 in 19-55 
and 2(i7% in 19-59 aahilc the correapondinp aaerare 
canes figures were 0 55 and 0 '4 
So far as canes is concerned then the children of 
the residential homes h’d feaac diseased teeth than those 
of the priaate schools and mana fcaaer than those of 
the Lee schools at hoIJi inap-clions It niiisi be 
cmp'iasired again that the canes incidence ind extent 
bolli in residential homes and in priaate schoa's ire so 
low that improacmenis are incaiiibl) small 

Relation lictaaecn Stnictnre of Teeth nnd tlieir 
Siisceptiliilila to Canes In 19'n 
It aaas found in the late t suraea is in 1915 and all 
Ollier siir\c>s of this scries that aailhin each of the 
groups of children the better formed teeth -that is 
those asiih no hapop'isia— aacre less h ibic to c tries than 
the M hipoplasiic ones and lint the more seacrc the 
defect the greater the h bdit) to the disease (see T ah’cs V 
and VI) This is Inic for indisidiiil Ispes (inciso s 
canines and mo'ars) ••s asell as for all teeth lalcn 
together To demonstrate this paint figures are giacn 
for three grades of structure in Table VII 


Tirj- MI 



h O >**- 
ffcrlC t 

'ft tf C • 

1 fill 

rs 1 

\ n 


O'*' III 1 

1 

^ 1 

1 K • 

1 s 

a t it K 1 »T (V H ) 


1 ? 

> « 

too 

Orlcct T ii »» 1 

f7 T 

<?<» 

' ■> 

-T# 


T? f %rrT " i-tu ni— Vr» oT Jl »f*t4i la t*»T i t t i t» irt-** 


In all cases it asdl Se se~a that fo* a g sen g'lde c' 
St 11 tore I* -re aaas less ca les ar-rn- t'lc chi'dren 
frsa-n rrsde-t al homes I’l n r"ong 1' me in I'lc psiajlc 
s^hca’s I III ' s rcfcicnce to th s ps -i is made in the 
d a ..ssnn 


r - Ss 

7 s 

ni n's'-r of Idlin-s brn- p c —I It r i 1 b- j - cd 
out haaeie I'lit s'l-' th oas o' If r c r i i a 

caaiiies in the resid-ntnl 1 amca were ac a sn-ial’ i( ^ 
gndine' aah 'c fc acr ( " lo't'-ptaile s' i o’ caa mrs 
aacre g r idcj as C, 

St iinirg of the Surface 1 ranict 
The sup- Ills aim"| o' dcs Ji nu tee h as'i h is 
o'icn cisntincd to th- nnrii a) m ir in an I mo' ( st 

has been camn enict! on ba sc - al asmle In pisi 

surae>s a no e w x made of ihis con hlion an 1 il as as 
found that those children with d 'lOitc b' o I man 
stiintne on fcas o naana ! cth hid less a in- thin 
children aailh n me or children v ho - l-clh sho ml a cli 
mte green a ainin, In this most recen* si raca tie e 
aaaa aert little diflcrrnce 1 clwrcn the canes so -( liLihry 


Tami 1\- 

•-Ir t 1 

I/-/ lyf Ct 

in in Pr h 

~ r»5 

1 •* ' 

s 




of Teeth 





! 1 

1 

1 S.t 

r'Ca- r- ■ 

i 

r* 

1 

. 1 

A 1 

I 

1 


j IWS 

17 JT 

1 1 

j 

1 * 

1 3 

V it*H ’ 

n )t j 

! I'v 11 f 

T "^1 1 1 ) 

'll* 

' ’ I 

r 1 

(' It 
< J 

I 

rs 1 

< 1 ' ) 

» A « ml • > 

1 ) 

1 O j 

{ * 

11 > V 1 

p It 1 

1 I'Ti \\-\ A 

1 l-lisu ll 

< n 

A t i 

r 11 

OO** 

tr -.-i 1 

t a 1 

VS i 

j u r 

» • (4 » » 1 

1 * 

ira 1 

1 

; 001 

< n 

Oorn I 

n II 1 

3 r) ' 

) •) 1’ M 

1 ''I 

tl 4 

( }> 

f ' 

s, , j 

rs 1 

! M ( 1 T 

1 < ( s' || 

i * 

1» 1 

' r < 

n 

of mouths 

with b'sel 

■’fi f bro in 

si tin 

'tnii 

llin e 

IS 1(1 


none (Table I\) but in this conncaion it mu t I' 
icmcmbcred I'lat there is acr, Int'c ciiics an wl -re 
Mouths aaiih green stun app-ar more sii ip'ib'e fill 
the numbers of chi'dicn With this stain ircsiill Irdcter 
mtnatc a-ariclics of co’ou acre omitted from th" c deu 
lations An inte rung pamt w--s t'le l3r,c propnitmn 
of rcsidentiil home chi'dren— almii! 5a at ci-h in p-c 
tun— aaho s'losed bio sn or hbel si ms is conpared 
with less than 7 csf p laetc s.hoal chi'Jicn 

Vimt of the Cariona rroersa 
The'e w’s an appirc-'t d-e e_'c in a c-st-d c~riri 
amnn" Imth g oup can pared with 19 5 In, |i,n 
have b-en di e parlii ro I* e p tmilfjrra n ei /m -a 


lion \rrt 

t 1 ^ a p adinl p o c v 

-an J i» 

js nn! al vavt 

c to Tp 

Cc n a Ap* i*”} 

r 1 I" 

1 r in jj*) It 

fro ) \c r 

to VC r Th** d 


ir*n t VO 

fioiip on 

t*'c oih-T li 1 ' I 1 re 1 

- c 

h C" l** f 

re* I 

rr 1 c 

t<-. h 

Win arre* c 1 

enn-A J ^ ^ 

0 ^ •‘’I rlic re i 

C rjo 

V '•eh cr>*n 

r cj ' 'i 

o*'’ 2 n t' - p js 1 


r 0 p So 


r > >• c'o c t' “-c ' 

' " r* 

’ n 1“ * >- »c 

ffci C 

to t* p CC 

c-v n t 

i - ic <5"* 'J 

J 

n 





56 ]\s 13 1951 


IIZLTH Of t YCAR OLD Cffll DUPN 


pjrrmi 

*!i£>icjil io ^ rMt 


cnrics (from 10 5'’^ to 7 I", c inous teeth) m cpitc of 
the fact tint at the time of the earlier >;urac> the total 
incidence and cvlent of the disease were already \er> 
low The prisate sehooh proup on the other lianil, 
winch had compiritivelj pood tooth structure in l9tS, 
showed no improvement while the decreise in canes 
in 1950 was \er\ small (I J 2'' , of the teeth were carious 
in 1045 and 12 7'X 1111050) I hus the number of cirioiis 
teeth found in homes ehildrcn was rceluced by neirly 
one third that in private schools by oiilv one tenth 
Whether the results (ivcn in this report arc merely 
periodic fluetu itions cinnoi be st iied No examinations 
of these two proiips were mule in 1947 which vv 1 $ the 
peilv vear for canes free teeth in 1 C C sehool children 
It IS possible althourh iinlil ely in view of the already 
small incidcnee of the disease tint the findinrs miphi 
have been still belter then 

W’hat are the reasons for these differences 7 A com 
pirison between the two surveys docs not suppest that 
the rcsluction in decay is due to iny v-ariaimn in the 
siigir content of the diets or to the amount of dental 
treatment given The strict ralionin" of sweets and sugar 
during the war ensured little dilTcrcncc in this respect 
Ihroiichout the post eruptive period for the two y roups 
examined in 1945 and those inspected in 1950 would 
have had if anything, more su"ar and sweets in their 
diet Again there was more treitment m both the 
groups seen in 1950 than in 1945 but for both years 
the percentage of carious teeth treated was much greater 
in private school children than it was in the homes 
children 

There miv be mans contributorv factors but in dis 
cussing the differences between the two groups examined 
in 1945 It was suggested on the basis of experimental 
and clinical investigations previously mule (Mclianbv, 
1923 1934) that the calcifvinp properties of the respec- 
tive diets It different periods both pre eruptive and 
post eruptive arc an important lev to the situation 
It was pointed out thit as 1 whole the relatively well to 
do mothers were more libely (from financial and other 
consider itions) to follow medical advice then becoming 
commoner, to take plenty of mill and some source 
of vitamin D during pregnancy and lactation than were 
the poorer mothers of the children who later entered 
the homes 

It also seemed likclv that the mothers in better cir 
cumstanecs would continue to give their children such 
foods in the months immediately after weaning Diir 
ing both of these periods the deciduous dentition would 
be developing and erupting In the post eruptive stage, 
however, there would often be a change in the respec- 
tive positions of the children from this point of view 
Dietary discipline would tend to be rcl ixcd in the ease 
of children living in their own homes especially where 
likes and dislikes of such things as eggs milk and cod 
liver oil were concerned In the communal life of the 
residential homes on the other hand, fads and faneics 
would be much less in evidence and regular meals of 
high nutritional and calcifying quality including an 
ample allowance of milk and a daily dose of cod liver 
oil, were the routine, as was ascertained in the course 
of the survey 

Thus It seemed probable that the post eruptive diet 
of the relatively well to do child might not be as good 
for the teeth as the pre eruptive diet whereas the later 
diet of the residential homes child would in all prob 
ability be much better than that given during the period 
of tooth development in this way the resistance to 


canes of the teeth of the private schools group would 
tend to be wealcncd, and that of the homes group 
strengthened 

In general these same relative conditions would in 
our opinion be Id ely to obt iin in respect of the children 
ex imincd in 1950 but where is the p'^c eruptive and 
post eruptive diets of the priv itc school children had 
probably remained on mu-h the simc level in the interim 
(thus resulting in a rather similar dentil condition) there 
had been certain important modifit Uions especially m 
the pre eruptive period in the diet irv of the boni's 
children The uaccr •’in qudity of diets talen bv cxp*c 
lant and nursing mothers and weaned infants in 193S-41 
(alTrcime the structure of the teeth of children seen in 
1915) had given place to the rationing of impartant 
foods plus a svstcin of specij) fool pmanlics for these 
viilncrihlc groups bv 1943-6 (when the teeth of the 
cliildren examined in the liter survey wee developing 
and erupting) This prioritv scli-mc should have been 
of especial benefit to ll c pao-er niOtbcrs the section 
of the population from which the majo ity of res denlial 
homes children are derived Th-sc priorities were avail 
able on ration books and would in many cases be talen 
as a matter of rotiimc cspccullv as the milk could be 
obtained at a rcvli^cj p ice or cvia free and the cod 
liscr oil and vitamin tablets were issued free to all 

In addition more was heme done than formerly 
through nnternitv md child wclfirc services to dis 
scminatc knowicdjc of belter ntiinlion Some of the 
children entered the homes at the age of a few 'seeks 
or months and in these cases there wo iW be tim. for the 
excellent infrnt and wcaninc diets given there to exert 
their etlcct on cdeificition, esp ciallv of the deciduous 
molars In such homes feeding had become even belter 
than in the early w ir period owing to stricter pi inning 
and supervision thus increasing if anv thing the favour 
able post-eruptive infiucnccs of such diets 

TTic vvorl of Sclnotr (1939) and Collett (1935) and a 
small invcsiipalion by Kmc (1946) suegested that the 
earlier in life the children were admitted to the orphan 
ages and the longer the period of residence the less the 
incidence of dccav Tlicrc was evidence of this natiuc 
in the data obtained in the 1945 survev though it was 
not published the results obtained in 1950 arc now 
being anilvscd from this point of sicw 

The improved dental structure observed in the rcsi 
dcnlia! home children in 1950 can therefore largclv be 
attributed to the belter nutritional status m the period 
of early tooth development as compared with the similar 
period for the 1945 group This would of itself tend to 
result in a reduced canes incidence but in regard also 
to the post eruptive diet these children leaeime a com 
miinal life would appear to benefit greatlv Not onlv 
are tlic diets in residential nurseries and homes well 
pliinncd, but under the British rationing scheme there is 
and has been since 1942 (Ministry of Food 1947), actu 
ally more of the important foods available per child 
in these homes than can be obtained for children living 
with their fiimilics Moreover m the latter ease any 
special allocation for the children may be all too often 
pooled with the food for the rest of the household 
Furthermore these children have far more say than 
those in the homes in regard to what tliev will or will 
not cat, and in many instances thev arc able to spoil 
their appetite by eating food of low nutritional value 
between meals 

In our opinion, few families in Britain whatever their 
economic status provide for their children diets which 


Jan 13, 1951 


11 Cl H OF 5 YEAR OLD CHILDREN 


Bamsu 

Medical Journal 


57 


are as good in their c ilcif\ ing propcrlic- as those scraed 
m children s residential homes to da> and in few is the 
intake of cod h\cr oil and c\cn nnlk lit clj to be nearly 
so rcgiil vr or so long maintained It scenis to us there 
fore ihtl the csccHcnt diet given in these homes is 
responsible for their low cirics me denec The rcdiic 
tion noted since the previous survev live vears ago is no 
doubt parliaJlj the result of improvement in dental struc- 
ture but It ma) have been enh meed bv the even better 
diets provided for these children in recent years 

It IS a challenging thought ihil on the whole, children 
brought up in orphanages ind other public institutions 
have a better chance of remaining free from canes 
(at least up to the ace of 5 vcirs) than children of the 
same ige brought up in pnvatc families 

Siimniar) 

The new resulls given in ilns r'prr arc compiled from the 
individual denial charts of a viirvc> in I9'0 of 547 children 
aged S \cirs living in homes (orphanages and institutions) 
and AfO children of the same igc attending independent and 
private da) schools mainl) in London and surrounding 
counties 

T7iesc two gronpv of children are compared wilh similar 
groups esammed m 19-5 md with each other as regards 
both dental structure ( leeordinp to the standards originatt) 
set up b) Mi) Mcllanb)) and ciries incidence and extent 
Reference is also made lo survc)S among LCC school 
children in 1945 and 1949 

Among the children m the homes (ooih structure was 
found lo have improved since 1945 there now being 42 0% 
of the Iccih free from both gross md M h)poplasia as 
compared vviih 42 3 « previously Concurrcnily there was 
also a rcdoclion m canes incidence from 10 5% to 7 2% 

The private selioot group showed much the same average 
structure in I9so as before svliilc the cirics incidence had 
declined onl) si ghll) 12 7% of all teeth being carious as 
compared imli 14 2 o previously 
The avenge dental striiciurc of the residential home 
croup slill lagged bctiind that of the private school children, 
but Ihc dilTcrcnce between the two groups was not as great 
as before 

In spile of worse denial structure the children in the 
rcsidcniial homes had a lower canes incidence and extent 
The relationship bclvvccn dental siruclurc and canes in 
both groups in 1945 and 1950 was such ihit llie greater the 
degree of M hypoplisia the greater was the liability of the 
teeth to canes hut for each gndc of structure the residential 
home children had less dcciy than the others Tins relation 
bclvvccn structure of the teeth and liability to decay has 
been ob erved in all similar surveys where the same standards 
have been adopted 

In cich group of children there was an increase in the 
amount of dental treatment both fillings and extractions 
but pirticularly Ihc former At cich inspection the pcrccn 
lagc of filled teeth among the private school group greatly 
exceeded Hi it among the residential home children 

Approximately 33% of Ihc children from residential 
homes showed black or brown staining on their teeth in both 
years as compared with only 6 7% and 4 8% in the two 
groups of the private school children 
Suggestions arc made to account for the differences found 
in both structure and canes incidence between residential 
homes and private schools and for the change occurring 
between 1945 and 1950 

We would like lo pul on record our grateful thanks to the 
many people who have so generously assisted us and without 
whose help this survey would not have been possible Porlicularly 
we acknowledge our indebtedness lo the medical officers and 
governing bodies for permission lo examine Ihc 5 year olds In 
children s homes and to the superintendents matrons and 
Icaclicrs who helped with the actu il mspcctions In the case of 
the privalc school children we thank sincerely all the pnncipals 


and teachers who so willingly gave us time and assistance to 
further our researches We also much apprcaated the help given 
by Miss Irene Allen of the Medical Research Council s Siaiislical 
Department 

REITRCNCtS 

Anderson P G Williams C II M Haldcrson H Summer 
fcldt C and Agnvw R G (1934) / Amer dent Ass 21 

1449 

Collcil A (1935) Tidsskr nnrske Lneeeforen No 22 
Coumoulos H (194(0 Nature Load 158 559 

and Mcllanby Nl (1947) British Medical Journal 1 751 

Davies J It (1939) Bnl dent J 67, (6 
Dcvcrall A (1936) Spec Rep See rned Res Coun Land 
No 211 

King 3 D (1940) Ibid No 241 

(194(0 lancet t 646 

Mcllanby M (1923) Brit dent J 44 I 

(1934) Spec Rep Ser rned Rex Coun Lend No 191 

and Coumoulos II (1944) British Medical Journal 1 837 

(19461 Ibid 2 S65 

and Mcllanb) II (1948) Ibid 2 409 

Mcllanby II and Mcllanby M (1950) Ibid 1 1341 
Ministry of Poo I (1947) Our food To das No 3 
Scliiotz, E H (19491 Bril deal J 66 S7 
S(oncs H II Luwaon P I Bransb) E R and Hartley H O 
(1949) Ibid 86 263 


rosTcnioR gastro-enterostomy 

IN PEPTIC ULCER LONG-TERM 
RESULTS 

n) 

DOUGLAS H Cl ARK, Oi 1\1 , T R C S Ed,, F R F P S 

(from the Peptic Ulcer dime llVSffrri Infirnwo Clasgott) 

Gistro entcrostom) in the trcitmcnt of peptic ulcer has 
been the subject of many reports, often conflicting and 
in recent vears seldom fivourable Although today 
abandoned by manv there arc still some who champion 
Its cause In this country Sir James Walton (1950), 
on careful and complete follow up of a large senes of 
cases, has found a constant incidence of stomal ulcer of 
only 2% but most other workers put the figure much 
higher, even as high as 40% The results obtained by 
Heuer (1944) agree with the experience of the majority 
of recent writers In his senes of 159 cases followed 
for periods of 3 months to 10 years (85 followed from 
5-10 years) 21 4% developed recurrent s)mptoms 
In comparing the end results of gastro entcrostom) 
and gastrectomy, Heuer found on both short term and 
long term follow up that the outcome was 10% in 
favour of gastrectomy but as he pointed out this 
advantage is reduced by Ihc lesser immediate mortality 
of gastro enterostomy To the debit side of the gastrcc 
lomy will hue lo be added a still undetermined but 
probably considerable percentage of unsatisfactory results 
in the form of small stomach ’ syndromes It is also 
probably fair criticism of the more extensive procedure 
that when medical men, and especially surgeons con 
tcmpinic operation as a personal issue gastro enterostomy 
IS given more than fleeting consideration 
With such thoughts in mind, it was felt that a further 
report on the results of g istro enterostomy stressing the 
long term results, would be of interest 

Clinical Malcn il 

The material in this rcsicw consists of 330 patients 
subjected to gastro enterostomy for peptic ulceration 
during the 14 years between J iniiary 1, 1924, and 
December 31, 1937 All ciscs were under the care of 
one surgical unit in the Western Infirmary, Glasgow 



58 Jan 13, 1951 POSICRIOR GAS! RO RNTFROSIOMY IN PERI IC UI CLR 


All cnnic from G1 i<;qo\v ^n(l ndjiccnt di'itricts The 
nnjonU were ci?cs of ticciivc op rntion In m’C oaia 
gTitro cnluroslom) w is performed U ll’c time of closure 
of a pcrfontion In two casts (astro tntcrostom> with 
ligation of vessels was performed for hitmitcmesis 

I ollnw up 

An attempt was m ide to trace all the survivor' and 
recall them for c\ munition Altoi ether lf>5 patients 
Were trittd and were interviewed 21, now at a distincc 
in the U K. or ibroad tould he contacted ont> l)> 
letter question irv With the aid of the a'lnon-r Red 
Cross workers mil other vohintirv or( ani/ations 50 
Were triced and found to have died I he inform ition 
available from their records relatives, f imilv doctors 
and death ccrtificitcs allowed of some isscssment illicit 
second hand The rcnuiininr 70 despite all effort 
rem lined untraced Manv of these pitients had lived in 
an arc I which had siilTered from eneniv iction Ihc 
total number of ciscs traced includim 21 opentivc 
deaths was 2(!0 out of 310 — that is 7S 7 The mi cs 
tigation was carried out during 19-1'? and 1919 

It IS probvbli inaccurate to cl urn this stud> as a 
follow up Recapitulation would be i more ipt term 
since manv of the ciscs were being seen for the first 
time 11-22 >ears after the event Where patients were 
known to have reported to other hospitals at home or 
abroad, inform ition was obtained from these hospitals 

The distribution of the cases bv oper ition >car .md 
their appropriate places in this follow up arc shown in 
Table 1 Table II lists the cises according to dn( nosis 


T*BLn I — DUIrtbullon of Opfrn Ion Siini\orj by leer of 
Opfrptlon 


Ycir 

Trace il 
Al«»e 

Traced 

Dead 

Untra-^d 

Toul 

1924 

2 

2 

4 

8 

192J 

f 

2 

1 

) 

1926 

10 

2 

( 

IS 

1927 

9 

1 

7 

17 

19.8 

12 

3 

7 

24 

1929 

14 

1 

4 

19 

1930 

17 

3 

6 

-8 

1931 

22 

5 

6 

33 

1932 

20 

2 

6 

-I 

1933 

17 

7 

5 

21 

1934 

21 

8 

5 

34 

1935 

8 

6 

5 

19 

1936 

14 

0 

3 

17 

1937 

n 

4 

5 

23 


186 

50 

70 

306 


Tahlc II — Disinbution of Operation Siir\l\()rs by Dlajinosls 


DloRno^is 

Traced 
Alive 1 

1 Traced 

1 Dead 

Untraced 

Total 

Pyloric stenoMS 

19 1 

7 

5 

31 

Duodenal uJu;r 

136 i 

30 

61 

247 

Gaatnc ulc4.r 

11 

13 


28 


186 

1 

50 

1 

70 

306 


Asses^meut of Re^idtK — Tl^c rc^ivilts h'xvc been (Imdcd 
into (a) satisfactory — those entirely free from symptoms 
— and (b) unsatisf ictory — those who at any time since 
operation (I) have had pam of ulcer type (2) have 
suffered from hacmatcmesis or mehena (3) have been 
treated in hospital for medical or sur<,.ical treatment of 
peptic ulceration (4) have had x ray evidence of stomal 
nicer or reactivation of the original ulcer 

Grades of Seventy — The cases grouped as unsatisfac 
tory vere not all poor results Many though not cuicd, 
benefited by the operation Accordingly these results 


P*m«i 

^frirtCAL i<r 

were further gr id"d into (n) severe — pain as scvcrcasor 
more severe th m before operation , those who lud com 
phcitions or who had required iiirthcr oper ition hccatisc 
of p'ptic tiRer (b) Modcr itc— pam less severe and 
more e isitj controlled bv food and all alu (r) Mild— 
pun slqht infrequent and v' ith djspcpsii (flatulence 
lieirtbiirn etc) winch required diet rcvttietioas md 
all ah therap) mioimting to some limit ition of the 
normal mode of life 

I iiiliiri Cline — Ihc onset of sjmp'oms after opera 
fion Ins been dilcd is ,accurilcl> as possible The p-r 
eentage of iinsatisfaetor) results for eaeh follow up 
)cir for the entire senes of pitients traced (cacluding 
the immediate past op-rative elcaths) sv's cilciilatcd and 
plotted in i fit lire curve Simil ir curves were plotted 
scpiritel) for severe modcr lie and mild relapses It 
should he noted that for thi stud>, anv pilicnl who had 
sjniptoms whieh miounled to m unsaiisfactorv result 
vs IS considered as such from the onset of the recurrence 
through the rcmtinine vcirs of folios up that is the 
curve was charted on the basis once i recurrence alwavs 
.a reeurrcnce llicrc was no moelification of the cunc 
for those who for cxanip'c hidonlv four sears ssanp- 
loms in IS VC us of follow up Sirnilarlj, those cases 
modified b) fiirllicr surgieal or medical Irnlmcnt were 
repuded IS fiihircs fton the ons't of ssanploms This 
method no doiihl rep events a more glooms picture thin 
a jcir to veir assessment would but in view of the j cats 
tint had clipscd since operation it was thought that the 
more simple method was a sulheicnt tax on the m-mor) 
of the patient and limited the scope of his imagination 

Resnlls 

Tile relapse rates for >cars 1-20 have been calculated 
but onl) those of the first five )cars and for the 10th 
15lh and 20lh >cars arc listed in Table 111 The failure 
curves for totil severe, moderate, and rtuld relapses are 
shown in 1 le 1 

»t ?t I 



Fio I — Inciilcnee of totvl severe modcrolc and mdd relapses 


Tantr III •^Ctimtihlbe Inclitence of Retapses 


Year of 
Follov. tip 

Obverved 

1 Percentage Rclap«» 

Severe 

Mcnlerate j 

Mild 

Total 

1 

■‘36 I 

8 89 

1 27 1 

043 

10 59 

2 

2 8 1 

14 47 

4 3S 

195 

2 80 

3 

2-6 

IS 14 

5 75 i 

7oa 

K»97 

4 

•• 4 

17 83 

5 81 1 

8 48 

3“* 14 

5 

2 1 

19 45 

6 7) 1 

9 1)5 

35 29 

iO 

21M5 

21 30 

8 73 1 

11 16 

4t 19 

IS 

IM 

-5 18 

9 .2 1 

9 .. 

4162 

20 

40 

25 00 

17 30 1 

*0 00 

6. 30 


It Will be seen that the incidence of relapse is most 
marked in the first live years 35'V having relapsed at 
the end of that period Tlicrcaftcr there is a slower but 



Jan 13 1951 


POSiruiOK O ASTRO ENTLROSTOMY IN PEPTIC ULCER 


BRrnsii 

Medical Joursai 


59 


sleidy increase in incidence In approsim He figures it 
maj be said tint after a p"nod of beuveen 15 and 20 
scars 50% base remained ssmptom free Compared 
ssith their pre operatise state 12 S were markedls 
improved 12 5%, though improsed stdl suffered con 
siderablc disability, and 25" were no better or worse 
In other words in 37 5" the results left much to be 
desired 

Factors Influencing Results 

The total relapse rates and the cumulatisc incidence 
of scscre moderate and mild rilipscs were calculated 
separately (I) for duodenal ulcer castric ulcer and 
p>loric stenosis (2) for males and females (3) accord 
ing to age at time of operation and (4) according to 
length of pre operatise histors 

1 Duodena! Ulcer Gastric Cher and Py lone Stenosis 
— Of the eases traced 1S6 were duodenal ulcer 24 were 
gastric ulcer and 26 sscrc psloric stenosis It is neces 
sary to define the last named group for there arc many 
degrees of pjloric stenosis and it may be organic or 

« I I 



Flo 2 — Companion ol total lelapscs in duodenal ulcer gastric 
ulcer and pylonc sicnosis 


spasmodic or both In this paper eases svcrc assigned 
to this group svhen there was x ray evidence of consider 
able retention and when copious vomiting characteristic 
of gastric delay, was present Pam was not a marked 
feature of these eases The total relapse rates are com 
pared in Fig 2 In the duodenal group the relapses 
mount rapidly to 35% in five years In the subsequent 
15 years a further 27% recur In the gastric ulcer group 
the large failure rate in the first five years is partly 
explained by six cases of carcinoma of stomach the 
operation having been performed in the belief that these 
ulcers were siriple In the group with obstruction 
though considerably better, the relapse rate is sur 
prisingly high — approximately 25% However, it was 
noteworthy that in cases of pyloric stenosis the relapses 


on the whole were less severe in marked contrast to the 
duodenal and gastric ulcer groups in both of which the 
incidence of severe relapses was considerable (25% at 
the tenth follow up year) 

2 Sex — In the series traced there were 200 males 
and only 36 females In Fig 3 the incidence of total 
and scscre relapses is plotted In view of the disparity 
of numbers fair comparison cannot be drasvn howeser, 
the impression is gained that whereas the total relapse 
rates are similar the incidence of severe relapses in 
females IS markedly less 

3 Age at Operation — The cases traced were placed 
in the following age groups under 30 (44) 30-39 (81) 
40-49 (60), and 50 and over (51) The total relapses 
are compared in Fig 4 The findings show that the 
results of gastro enterostomy arc better in the older age 
groups Though not recorded in Fig 4, it was noted that 
the incidence of mild and moderate relapses was much 
the same m all age groups The better results in older 
patients represent a lower incidence of severe relapses 


KKt 1 Ct 
UK MKL 



Fio 4— Total relapse rales according to age group at Ume ot 
ope ration 


4 Duration oj Pre operant e Ulcer History — In order 
to study the relation of the end results to the pre 
operative history the cases have been allotted to four 
groups according to the duration of symptoms prior 
to operation The number of cases in these groups is as 
follows 1-4 years 66 5-9 \ cars 76, 10-14 years 57 
and 15 years and over, 37 The result is shown in Fig 5 
from which it will be seen that the total relapse rates 
arc closely similar in the different groups Although not 
shown in Fig 5, it was noted that the incidence of 
severe relapses was considerably higher in the 1-4 years 
group than in the group of 15 years and o\er As an 
example, at the tenth year the short duration group 
gave 30% severe relapses compared with 11% in the 
long-duration group TTie better results in the last group 




Pio 3 — Comparison of total and severe relapses in males and 
females 


Fio 5 — Total relapse rates according to years of duration c, 
pre-operative history y 


CO n 1051 POST TRIOR C. ASTRO CNTCROSTOMY IN pcnnc UI UK 

w ^ ... ^ , . „ 


nrc probibI> due to tlic fnct tint it contnini a hi} her 
proportion of older paticnti of women piticnte and of 
piticnts with pvlorit •itcnoei': Tlic rtsiilts in the ^-9 
jcir and 10 l-l jcir (roup? arc simihr and mtermerhate 
— for example the ?e\cre rchpee rites it the tenth >cir 
beine 27' iiid 23'\ rcspecliscR 

IiichUnec of Major Compile illoiis iind I^tc Deilh? 

Oier the totil fo'low up pmod pistro intcstiml 
hiemorrlnic occurred in 20 piticnts (12 29) Tlicre 
vs ere Inc perforations m four patients in incidence of 
2 I Mi Nine pitients (t S ) found it ncv.c»Mr> to 
underfO furllicr opcrition for relief of svmpioms f our 
of the pitients alrrulv noted is Inviti}, suvtuncd a 
lncmorrln}e also elected to iindcrpo i further open 
tion Thus the ‘ li ird tore ‘ of recurrences inioimtcsl 
to 1SI% Almost two thirds of these severe tchpscs 
occurred within the first Inc veirs No cave of pastro 
jejuno-tolic fistula vvas entountered in the senes traced 

1 iftv of the pitients tritcvl we c found to have died 
In the 111 ijorilv the cause of dc ith vs is unrcliiiet) to 
pcp'ic ulcer Tour patients died from tames directl> 
attribut ible to peptic uIccr~two as a result of pis 
trcctom) for stomil ulcer and two as a result of 
haemorrh iic 

In SIX of the pastric ulcer cases traced the cause of 
dcith was circinomi of the stomach In onl) two of 
these was ncvropsv performed in one ni ihpnnnt chanpe 
had supervened on i simple lastnt ulcer In the other 
case nctrops) details were not n iilable Hiree died 
within three jeirs, the renuinder within Ine >cnrs 
Gastro cntcrostoni) In leavmr the ulcer eirries an 
immediate risl of nintatcn diipnosis iiid a later risk 
of milipnint change Circmomi of the stomach was 
the tausc of death m tlircc cises of duodciul ulcer 
death occurring at 10, 12 and 17 jcirs after the 
opcrition 

Discusviun 

Ihc results of this invcsiipition conlirm the hiphcr 
relapse rites reported in tilt liter mire It must be 
stressed, however that the method of issessmenl used 
has presented the results of the operilion m the worst 
possible light A jcartojcir assessment would no 
doubt present a more pie ismp prosp.et Manv thouph 
not ‘ cured were consider ibly improved Aincinp those 
were sever d who had siilTcred a compile ition as an inci 
dent in an otherwise uneventful post opcr,itive history 
These cises iccordmg to the criteria used were noted 
as severe relapses Similirly, a few eases hid a total of 
only about four years stom icb trouble in ns many as 
15 follow up ycirs Viewed from the vantipc point of 

cure of peptic ulcer by oper ition the present results 
assume a proper perspective In round figures after a 
period of 15-20 years 50 {, rtm lined symptom free 
and 12 5% whose symptoms were slight were markedly 
improved In the rcni lining 37 5% the operation had 
failed 

In view of this high fiiluic nte it seems pertinent to 
try to obtain a true assessment of the value of the opera 
tion To do so it IS necessary to compare the results 
obtained with those expected without treatment and with 
those obtained by other methods of operation — for 
example gastrectomy Furthermore, since gastro 
enterostomy possesses the cardinal advantage of low 
initial mortality, the question arises how casts liktiy to 
gam permanent benefit by this procedure might be 
selected pre operatively 


t nniparhon wllli I'nlmlti! Ca n 
Ohvioiisly It IS not now possible to obtain for study 
ns a control in untreated iroop of cis*"- stricilv com 
parable with tlio'c repined above Information regard 
in} n somewh It stmil ir }rmip of t v v is however av>d 
able from tlic tollow up sludic of Illmgaorih rl cl 
(1916) These studies refer to the pro revs after per 
forited peptic ulcer and relate to pitients from the seme 
region ind of the sani" sncp! class Ihc •'■e and «ex 
distfihiilion in llic tvso senes arc rcmarlably simiia'’ 
and by a toinculentc the p'oportion of gavt'ic to 
duoilcnd ulcvtv IS almost idcnticil The two are 
similar at o in lint ificr disclnrg’* from hospital thci 
dietary co itrol and anti ••cid tre itmcnl were gcnenllv 
haplnrard Pitients in the rastro cnicrostnmv coup 
with pvloric siciio IS have h'*cn exvludcd siacc onstruc 
lion IS not a factor m lit* petfortt on senes rd would 
b, inclusion improve the results of the ptcsenl «c ics 
They dilfc of coiirs- m that la tic Illnewonh series 
the sole criterion fo' in liision vvas Ihc fa^t of ji* fo a 
110,1 and in onlv a smill proportion hid the svmplomv 
Is^forc perfo alion been severe cno igli to warrant surgi 
cal tre Itmcnl tiles'- two dilTcrcnecs wou'd seem to 
imply a b*llcr pro na'tv av re; itils rcluf of svmp’oms 
and so m comp time the results the sc-dcs woild be 
weighted against the p esent senes 

In I ihlc IV the incidence of rvlapes m die present 
senes and tint ifler petfot ition ate compi cd at the 
cnvl of tlic fifth follow up year I ig f> shows tlic yeir bv 
year comp in on for the lust live vears In I ib'c V and 

Tviitr IV — rne)e ' hr’ "in Ct grr/ios *n’li Per) r-fws 
Crrin 




TamJ* V — of tony 

Lotf\j /i( n HI ^ rctfi tc ion Sr'lO 



1 of i 

1 t * ' i 

ii-*- 

C Hi att-vni 

PfTvni 

>’ 1 

! 10 s 

Tcff >r«ll nv.ri '(lUit ^ rf M 

(S text) 1 

t ''lO 


Tip 7 the incitlLncc of major comphcilions is similarly 
compircd Herv however it should be noted that 
Illiniworih or nl (1945) arrived at Ibnr csliiralc on the 
basis of lfi6 pitients f^ollowcd for the full five years 
but used additional informition from pitients followed 
for shorter periods 

Compirctl with the untre itcd group, castro 
enterostomy his halved the relapses and the 
complications 

Ct)mi)arifon »lth Cmcn Trrntetl b) Cn^trrftnm) 

Though the results reported for' gastrectomy viry, it 
seems clear tint recurrent ulceration is infrequent not 
more than 4'\' (I until 19''0), and in more extensive 
abl Ition of the stomach (Visick 194S) this complication 
has been reduced to nil Comparison on this score 
atone leaves no doubt about which operation is prefer 
able The position becomes less clear, however, when 
assessing the importance of those disturbances of all 
mentary function which arc the sequelae of gistrcctomy 
There is no unimmity m the reported results is regards 
the incidence, seventy, and duritcon of these comphea 



Jan 13, 1951 POSTERIOR CASTRO ENTEROSTOMY If^ PEPTIC ULCER . oimra 61 

Meoicai, Journal 

incidence advocated the use of gastro enterostomy, particularly m 


7o 



YEARS 

Flo 6 — Companson of rchpscs after gastro-cnteroslomy with 
tho'c after perforation 


tions Muir (1949) found that 75% of patients in his 
scries suffered at some time from the dumping syndrome 
and that m 34% the patients were considerably handi 
capped According to the same author, although this 
complication sometimes disappeared within three months, 
not infrequently it persisted for years That they arc 
better off with their dumping syndromes than with their 
peptic ulcers is readily admitted by most patients— but 
not by all (M D 1949) 

Comparison on the basis of recurrent ulcer is in favour 
of gastrectomy by a wide margin How much this 
- margin will be reduced by small stomach syndromes is 
as yet tinl nown 

Selection of Cases for Gnstro enterostomy 
The occurrenec of good results in at least half the 
cases has encouraged previous authors to inquire into 
methods of selection For example many surgeons have 

PERCENTAGE 

INCIDENCE 



y - A n 5 

Fio 7 — Comparison of complications after gastro enterostomy 
with those after perforation 


elderly patients with a long history, in women and in 
patients of either sex with severe pyloric stenosis _ Refer 
ence has been made above to the results to be expected 
in these different categories of cases 

The pre operative gastric acidity has been used as a 
criterion by some surgeons on the hypothesis that stomal 
ulcer is less likely to occur if the acid level is low 
Several workers have found this criterion unreliable 
For example Holman and Sandusky (1938) and Nicol 
(1942) found little relation between the reduction in the 
acid concentrition and the clinical improvement pro 
dueed by the operation High pre-operative and post 
operative levels of free HCl were consistent with good 
results On the other hand severe relapses were encoun 
tered in patients with low acid levels before and after 
operation 

Taylor (1944) has based selection on gastroscopic 
appearances and has succeeded in reducing the incidence 
of recurrence to a low figure Where the mucosa is very 
vascular and the rugae exaggerated relapses tend to 
occur after gastro enterostomy Gastrectomy is advised 
in these cases 

Walton (1950) is convinced that certain people are 
more prone to develop gastro jejunal ulceration Such 
patients tend to develop duodenal-ulcer symptoms early 
in life , there is a high free acid response to a test meal, 
and both radiography and gastroscopy reveal hyper- 
trophy of the mucosal folds 

Visick (1948) carefully examined stomachs removed 
because of recurrent ulcer Abnormally extensive 
mucosal folds were not a noteworthy feature 

Conclusion 

In gastric ulcer in view of the high relapse rate and 
the possibility of mistaken diagnosis and malignant 
change, the operation of choice is gastrectomy 

In duodenal ulcer the present investigation suggests 
that the short circuit procedure has a place in the elderly, 
in women, and in organic pyloric stenosis These factors 
however, carry no guarantee of permanent cure With 
regard to the large proportion of duodenal ulcers requir 
ing operative treatment until some means of selection 
IS forthcoming, gastric resection will remain the most 
certain method of cure, an opinion which may require 
some modification when the true incidence, severity, 
and juration of post-gistreclomy syndromes are belter 
known - - 

I am indebted to the tale Mr Roy F Young and to Mr George 
Dalziel for permission to use their records I also wish to tliank 
Professor C F W Illingworth for his helpful cnticism 

References 

Heuer G J (1944) The Treatment of Peptic Ulcer Lippincotl 
London 

Holman C and Sandusky W R (1938) Amer J mea Set 
195 220 

Illingworth C F W Scott L D VV and Jamieson R A 
(1946) British Medn'al Journal 1 787 
Lancet 1950 2 373 
MJ9 (1949) Lancet 2 907 
Muir, A (1949) Brit J Siirg 37 165 
Nicol B M (1942) Lancet 1 466 
Taylor H (1944) Proc R Soc Med 38 95 
Visick A H (l948) Lancet 1 505 
Walton J (1950) British Medical Journal 1 206 

A free booklet District Ntirsttig in the Metropolitan Police 
Area gives the names and addresses of all the nursing 
associations in London It is available on request from 
the Central Council for District Nursing 25 Cockspur 
Street, London, S W 1 



f )2 Jas n lyM 


IRON rNCEPIIAIOPATHY 

nv 

C. AIIAN niKCn, Ml) I lie I* 

A*>r) 

MOUWINNA inu Mil. IlClilr, I) C 11 

(Tram Char Itrm UotpUil InfrlJl 

The problem of rcfnclor\ mtcrocMic l)vp>thromlc 
-imemn Ini been latisf lelontj sohetl in nnn\ t ties 
b\ the intr ivcnoni ndnitnistnlion of an iron Microic 
complex (Nixmii 1917) Nexcrihclcsi iron bj intri 
\enoiix injection nncl c\en b> mouth ix not cntircl) 
without risk Iron poisoninp wax quite common for 
some xenrs .ifier PKrre Illuiil introtluccd hix finnui 
pill in 1812 No further casex xxctc reported until 
recent >carx when after a period of nejleet, the prac 
tiec of pixine inorpanie iron xilix m lirpe doxes b> 
mouth b-came cxtablixhcd ae iin ax iixcfiil treatment for 
hxjochromic anaemia Rcccntl> ferroux xulpliilc b) 
mouth has cauxed acute paxtritix and death from hepatic 
f ulurc 

Cerebral xjmptomx follow inj oral iron niedieition in 
man arc rare llurxt (1131) reported the case of a xerj 
anaemic xxoman of 58 (lib 18' ) xxho too) 10 pr (26 p) 
of iron and ammonium citrate a da> On the 22nd da> 
of treatment (her Ilb liaxinp risen to 5 1'') 'he com 
plained of xexcrc headache and had nine conxulxionx 
within 24 hotirx flctwcen the altaclx xlic wax xcmi 
conscious and had twitching of the riibt xidc of 
the face She made a pood recovers R-xond xixing 
that the cerebral x>mptoms rcicmbled those of lead 
cnccphalopath) llurxt pave no opinion on their 
mechanism and lux title ‘iron encxplnlopatli) 
seems I ardly justified on the data published 
Napier (1936) reported a case of presumed iron 
cnccphalopathj in an Indian man aped 30 who after 
receiving 46S gr (30 p) of ferroux sulphate in 26 days 
for a simple hypochlorhydric anaemia (lib IS” ) had 
a senes of seven fits during a day lie also refers to 
tlic case of n wom'’n who had fits following a daily 
dose of 12 gr (08 g) of ferrous ammonium citritc for 
33 days Whether the iron had been responsible or not 
seems doubtful, ns the Wassermann reaction was 
strongly positive 

Mooney (1950) mentions intense headache follo’xving 
an intravenous injection of 100 mg of saccharated iron 
In the case recorded below severe cerebral symptoms 
occurred after the intravenous administration of iron 

Cnsc Report 

A houncwjfc Tfcd 54 of 'wenge mcntnl cipicdy attended 
hospinl on Jininry 12 1949 uiih n history of mcrcising 
dyspnoea and lassitude for three ycira and of ocdcmi of 
the ankles incl soreness of the tonj-uc for two months 
She had no dysplntia Her menses had been heavy until 
September 1947 when ihcv ccisccl There was no other 
h story of blood loss Her diet hid been intdcqiiaic though 
she had not lost weight There had been no previous 
illnesses and she h id had two normal pregn incics 
On admission the patient appeared pale There was no 
glossitis The pulse was regular the b’ood pressure U>0/70 
The heart wis not enlarged A soft systolic bruit was 
audible over the praccordium but was not thought to indi 
cate valvular disease No abnorm ihiy was found in the 
lungs abdomen pelvis or central nervous system 


Tintat 

VtimCAl /eXTHAL 

/nirifD.i/miit-— lib 41 , (6 p V ) R D C 3 -00 000 j'tr 
c mm ciilfiiir int'ex Ofi rciiciilocylcx Icxx than 1' 

\\ II C 7 100 per t mm - tlillcrcntul coiirl rorrril A 
fiictionil Icxi mcx1 xhowctl hwlxmine f'xt achloihyilria 
A tulini'npli Ilf the tlicu w ix num al Ilic iirire wax 
luifnnl A xliipnmtx uf bypocliromit microcytic (iron 
ilclicicncj) an icmn wax made 

I rofiTtx «r><! Trratmmr 

Intraxcnom iron tberapy x ax bet-un ti Inp a xo'ulion ol 
lacelnraled iron oxide (containinj. 100 mp of iron n 10 ml). 
On ll c a xiimpinm lliai eaxb I(io mp of iron ihould rai«e 
it c !i icn oylnbin b> 4'i ibe lolal rcqiiircmcnl for Ihii paiienl 
wax 1 *P0 mp 

On Janiiaix 11 and is rexpccluely 20 mp and <0 mp 
xxtre vixen lb- inj'tlionx temp naadc xlnwly into a xem in 
llie anlcvub tal fi xxa Oa ibe 17lh afier rcccump -0 nc 
of the iron ibe pali- il complained of di74incxx and o' 
tinpbnv in the li-ndi Mie alxo xialed lliat cxcrylbmc 
app'ared 'tnpy Sbe ih-n xoanlcd The injcc ion 
xxax dixcoatirii-d Afier ihix mi'ctionx were contini-cd 
xiaily none of ihcm I— mp pttilcr than 75 mp Only 
minor comptamu of naiix-a and general malaixc were 
made 

lly jam ity 23 lie ninth dax afier Ibe initclionx x -re 
xtaricxi a to'al iloxe of I'O mp of iron bad been adaiiai' 
tered On ibix day the palicnl complained of hcadach* and 
app-ircd In be very anxiot x Sbe taler xomilcd twice No 
injection xxax vixen Al 7 10 pm the mirxinp xia(I not'd 
that xltc xeemed xtranpc in Ii*r manner and somewhat dtoxx-xx 
At 9 10 p na xbe had a conxubion, after xxhich x! e remained 
xlecply un.oaxvioiix Her Iim‘'i were flaccid and her exex 
(I'xialcd lo the tithi Her pulxc rale xxnx 120 a mmu c and 
lie tlylhm irrcjiilat There xxax ro pulxe dcfcit I util e 
corxiilxiotix then oenirrcd al mterxalx of about 20 miriiicx 
Ijcli of llirxc bepan in the lefi hand and spread to in'Iule 
the left xide of the fate the left Icp and finally b-camc 
genet ili.ci! Tlie C S I prexxure xxax 210 mm and routin' 
laboralorx exammatu nx shiw ed no abnormality TTie 
Wax etmann reaction xxax n'patixc in both the CSF and 
the blood I arpe doxcx of panidchxde (16 ml in all) were 
pixcn intrinnixctihrly but the conxulxionx bccan c more 
frequent until it I am on January 2) they were recurring 
at fixe minute inicrxalx Tlcrcaftcr they ixecame Icxs ftc 
quent and were confined to the left side of the bx’dx Thex 
finalb ccixcd at 4 a m 

The piiieni remained iinconxctoiix during the next 12 
hours but rexponded lo pinchinj by proaninj, or by moxinc 
one or oilar lej Many mnule pelechiic were xixibic oxer 
the chcxl and armx and bruixinp had oamrred al the sites of 
pinchinp A mild left hemiplegia aflccting the arm more 
(Inn the lee was present this gradually improxed diirine 
the next three days Her blccdmi. lime xxa- 40 seconds 
and the clotiinj lime fixe minutes platelets numbered 
13 X 000 per emm the capilhry resistance test (Rumpel- 
Lecdx) xxas posiiixe and the urine xxas normal 

tty January 28 the patient xx-xs conscious and rational 
She xxas able to xxrite and to read a fexx xxerds correctlx 
but iiinbic to understand xxhat she read Al 5 45 pm she 
suddenly lapsed into a drxanix stale She sal up in bed and 
appe ircd to be eomplctclx detached from her surroundincs 
making no response lo the spoken word or lo punfiit 
stimuli The fexx xxorde she uttered (which often included 
green’ mil xcllow ) indicited a cross dysphasia 
Altliough tins speech defect xx is associUcd with a left 
hcmiparcxis she x\ is not left handed The only other sign 
of note was the presence of spontaneous nystagmus This 
ditamy stitc lasted for 10 hours 

By March 8 she xx is able to read accurately but a 
tcmlcncy prcxiously noticed to re id onK the right halt 
of printed lines persisted Her xisuil fields were appar 
cnily full but cooper ition was poor Her general condi 
lion was pood and she xxas able to xxalk xxiih issislancc 
She complained intermittently of occipital hcadiclie The 


IRON INCLRIIAIOI’MIIY 



Jan 13, 1951 


IRON ENCEPHALOPATHY 


ORmsH 

Medical Journal 


63 


hacmalological response (o the iron ssis e\ccllent There 
had been a good reticulocjtosis and the haemoglobin rose 
steadily to 82% (12 1 g‘\) on Februarj 2 
She was discharged from hospital on April 1 and returned 
as an out patient on April 30 Her haemoglobin was then 
92‘’o (13 6 g "o) There were no abnormal physical find 
mgs but she still complained of headache She was very 
anxious and she easily panicked Though able to carry 
out simple household duties she could not cook a full meal 
or do any shopping and was quite unable to make any 
calculation or to count change She has remained more 
or less in the same condition eser since but has become 
increasingly depressed at the persistence of her disability 
of which she seems fully aware Her haemoglobin level 
on June 1 1950 was 106% 

When last teen on June 24 1950 she was a littlcHmsteady 
on her feet She was depressed at times and tended to be 
muddled over money These symptoms were less marled 
than they were originalK An electroencephalogram at this 
time showed evidence of bilateral damage m the temporo 
parietal regions 

Discussion 

Two well known proprietarx preparations have been 
used many times in other cases without serious mishap 
On this occasion both were out of stock and ampoules 
of a privately made preparation were offered instead by 
the pharmacist and accepted for use It was not fully 
realized by all concerned that this preparation was other 
than had been safely used before It was a solution 
of saccharated iron oxide prepared from fern oxid 
sacch equixalcnt to 100 mg of elemental iron (Fe) 
and apyrog n (pyrogen free distilled water) to 

10 ml The saccharated iron oxide was dissolved m 
the dpyrogen with the aid of heat and the solution 
was filtered through filter paper while still hot It was 
filled into ampoules and autoclaved at a pressure of 
10 lb per sq in (0 7 kg per cm ’) for half an hour 
Subsequent analysis of the preparation showed that it 
contained the correct amount of elemental iron (Fc) 
and 21 6% of sucrose the pH being 8 7 
Compatibility with serum in iilro was demonstrated 
by mixing 2 ml of the solution with 2 ml of normal 
horse serum and 0 1 ml of the solution with 5 ml of 
normal horse serum These mixtures were incubated 
at 37 C for one hour and gave no macroscopic or 
microscopical evidence of coagulation or precipitation 
Similar tests with the patient s serum and that of normal 
human controls were negative It must not be assumed 
however that precipitation would not occur in vivo 
and Nissim and Robson (1949) found evidence in mice 
that a gradual precipitation of proteins did occur m 
VIVO and suggest’d that the compound was broken down 
gradually as the sugar part of it was metabolized The 
LD50 of the sample administered intravenously to mice 
was approximately 118 mg per kg whereas the most 
suitable preparations were found by Nissim and Robson 
(1949) to have an LD50 of 300 mg per kg 
The available evidence does not satisfactorily explain 
the production of cerebral symptoms The importance 
of using pure chemicals in making saccharated iroti 
oxide IS emphasized by Robson and Keele (1950) who 
point out that some of the more transient reactions can 
be avoided by using analytical grade reagents — ^for 
example 'analar sucrose Somers (1947) showed 
that very large doses of iron preparations given by 
mouth would kill animals resulting in convulsions and 
coma for which no adequate organic basis could be 
found Cappell (1930) studied the fate of intravenous 


injections of colloidal solutions of saccharated iron 
oxide in mice and rats They did not cause floccula 
tion in contact with plasma and so pulmonary embolism 
did not occur The iron was taken up by the cells 
of the reticulo endothelial system, and later formed a 
loosely bound compound with plasma proteins through 
which It was distributed to other organs notably the 
liver Some iron was deposited in the walls of the brain 
capillaries but it was rapidly removed and thereafter 
no iron was found in the nervous tissues It is con 
ceivable however that capillary damage, sufficient to 
lead to sub^cqucnt injury to the brain might be caused 
by some iron preparations 
Poison (1928) in attempting to produce haemo 
chromatosis in rabbits by injecting dialysed iron intra 
xcnously, found that pulmonary embolism presumablv 
from flocculation was easily caused bv long or rapid 
injections Ledofsky (1924) injected a 33°' solution of 
saccharated iron several times into eight moribund 
patients but no iron could be demonstrated in the 
brain tissue histologically Goetsch el al (1946) attn 
buted the toxic effects of iron to a heavry metal effect 
but this term is usually understood to mean the forma 
tion of a metallic proleinate when a soluble metallic 
salt is mixed with a solution of protein We know that 
in the present case the preparation used did not pro 
ducc a protemate with the patients plasma 
The analogy of lead encephalopathy is not help- 
ful, since the pathology of this state is unknown apart 
from the findings of arteriosclerosis and meningeal 
fibrosis in chronic case? 

Summary and Conclusions 
A case is reported of severe cerebral symptoms m a 
woman aged 54 after the intravenous administration of 
380 mg of iron in nine days The symptoms are tenta 
lively ascribed to iron encephalopathy but the mechanism 
of their production remains in doubt The use of certain 
proprietary preparations of iron for intravenous use is 
known to be valuable and fairlv free from toxic effects 
if these preparations have an LD50 for mice of 300 mg or 
more per kg and if dosage is kept below 100 mg of iron 
a day The danger of using unproved preparations is 
emphasized 

RCFERbXCES 

Blaud P (18321 Bull gi^n Thtr Pans 2 154 
Cappell D F (1930) } Palh Bad 33 175 
Goeisch A T Moore C V and Minnich V (1946) Blood 
1 129 

Hurst A F (1931) Gin s Hosp Rep 81 243 
Ledofsky E (1924) Wien klm Wschr 37 694 
Mooney F S (1950) Bnlish kledieal Jnnrnnl i 1267 
Nanier L E (1936) Indian nied Gaz 71 143 
Nissim J A (19471 Lancei 2 49 

and Robson I M (1949) Ibid ) 686 

Poison C 3 (1928) J Faih Bad 31 445 
Robson J M and Keele C A (1950) Reeeni Adiances in 
Pharmacoluev p 285 London 
Somers G F (1947) British Medical Journal 2 XQ! 


On Mav 31 1950 the Royal College of Obstetricians and 
Gynaecologists comprised 837 Members and 322 Fellows 
Seventy three of the Fellows belonged to the London divi 
Sion and 1 iverpool and Manchester togeiher contained 20 
the greatest concentration outside London Out of 31 
Scottish Fel'ows Edinburgh contained 11 and Glasgow 14 
in Ireland 9 were in Belfast and 13 in Dublin while 
Melbourne and Sydney (Australia) md Montreal (Canada) 
had 10 Fellows each 



r.t n Ml inniN in iri a 

MnnoiN IN inr iRHA'iMrNT oi 
I Pii i:rsY 

ii> 

t) R JONtS MI) MR CP 

Mrhctil /v< ^tri r \/(i I nic UmptUtI fur Str\i u\ 

Onriiij li ir Uei^nln r \U II t iil 

Diirini ific Iivl \eir'5 •cicri! nc \ inti cpilcplic 
ilivus insL bcciime n%-\ihWr for cltniv.!! ihc of lli- c 
Irovulonc ( Indioiic ) t welt Inown in tiu trcitmcnt 
of petit mil liiK piper II i repot on n trnl of 
metlioin ( incsontoin 1 nictli\l-5 5 p’ien\lcth>l- 
hvdintoin) \ ptepuition miml'i cffcvlisc rpiiiul 
otlicr \ lrl^llc^ of ipi!cps\ llie driu i lIiliiih. ills 
Tilled to phcnMoin tind n tPo rehted to tlie toxic »lrii- 
plicn\lctli\llud iniom ( nirvinol ) nnd to iroxidoric 
(IUi>;i m 19 IS)— I f ict of xoinc xi} ufiem e when im 
ndtrin!; itx toxic ilTectx It ix di'penxctl "lx < pml tiMet 
of 0 I p 

Clinic il In ilx were firxt nnde in 19)7 In 11 diet (I‘> tl) 
wlio rcr irded it nx xilinblc but potertti ilK toxic Reniltx 
were lirxt published in Aniern i in l'*!^ since when 
minicrniix reports upon its inc line licen iipde thini' h 
no dtliilcsl stud) Ins ipp'-irsd in the litstiliiri. of Ihn 
coiintrx 

I osni/o (I9!5 I9lfi 1947 I9!s) inmr ^o Inini 

dipbcnvllnd intoin lie ( dilinlol ) in n font seir stud) 
reported i fi07> rtdiution of fits in pitienlx xiiffcrinf 
from m ijor and niinor cpilep ) I oxn. clfccts wcie few 
ond the ibscnce of turn lijpertropln tiuI itoxn (tom 
mon to'ie xjmptomx nitli pbcn>tom) w n lU) tb’c ko/ol 
(1916 19)7 1950) lisin! doses of up to 1 S f i dn 
treTltd 200 pnlitnls for periods of up to four \cirs nnd 
found 1 90V rcdiitlion m frequent) of Ills csen iluniib 
the mnjoritv of cists were resist int to phenstoin 'ts> t 
of his c iscs stiffertsl from mi|or cpihps) but the drop 
was ilso of use in psscliomotor sti/uris tlioiqb not in 
petit mil Meibom ind pbtns tom were sometimes jnen 
together with ippircnll) n ssncrtnlit clfctl pheno 
birbitont ssns not used is metlioin done txirttd i 
wcllmirled soporific cfftct Him nnd Otio (I9J7) 
- tre ittd 20 C 1 S 1 .S of psschomotor tpdtps) ind found 
tint 13 wtre rtndtrtd ittntl frtc I ttitrm in ind Weil 
(1947) I Lltcrnnn ii <il (1917) nnd rcllirmin ind 
VictorolT (1949) m a trnl with 150 pilienis tonsidtred 
ncthoin to be birhl) ctTcctist in m ijor tpdeps) \ dti 
nblc m Jacksonnn epilepsy nnd of occ iston d os'- iii 
psjcbomotor ntlncls They stressed that good results 
sserc ichicscd when other remedies hid filled In p"tit 
mil the drug w is not of use And (19 IS) reported a 
group of 75 pnlicnts resist iiu to other meisures and 
found dmost complete control in more linn li df 
the tiscs of nnjor pssebomotor nnd Jncksomin 
epilcp,y 

Although \ dinble, it soon becime nppnrcnt tint 
mclhom was dso sometimes toxic ind that its use 
called for the same c ireful supervision ns with troxidone 
GioLs (1947) found tbit toxic rciclions de\ eloped in 
10% of pnticnts while of I^cnnox s (I94f>) cises 14% 
hnd a rash Kozol (1947) reported i 6% incidence of 
morbilliform rnshes during the first month of tre itmcnt 
but thought thnt renctions were mnde less Id cly by the 
use of smnil initial doses Loscaizo (1948) si itcd that 
n history of previous sensitization reactions was common 
in patients developing a rash and stressed the need for 
n careful history m this respect 


MFN I 01 I I’ll I PS') , rrn-,, 

^ ^Tl TAl lot 

Orov .in'ss wa tunmmnl) lepnrlcd as a sidcrnfccl 
of incilmin but f urn Inpirlroph) indatixia vhich«n 
often o'-ciir dutmi phenstoin Ireitmcnt, sserc rnr-ls 
'cen 

Minor blond eh uu cs v ere found in IS of retterm m 
ind Vietnro'I » (19.4) t ises and I ennox (1946) report d 
I rclilise Ismp'nevto is m '0 of his stics Olhc 
ilitlu) s often toi 111 ciit'-d on the iVvitrrcncc of n re! ti c 
IsniphOk' teas nnd iho of coMnophilia ih" lattc' par 
lieulirls in the p c'cnct of derm itilis 

S n >iis up site I toxiw efic-ts included iphstic anarinn 
ind cxfohitise ilcmitiiis In the Aniciiena Iitc iii c 
ihc'c ire repsrts of six fud cites of aplastic anaemia 
Old of ei Ides cs th U recovered I he reicirnns oceu red 
three to cobtc n msiths ifter stulme met'iom ll cr ip) 
\hhott mil Svliw h (19)0) m rcucsme the prob’em 
thou lit tint se loiis hloosi cli orders were not of sudden 
on<cl IS w i' held In sqm'* hut rep evented the su iden 
ctdinin itis'is of i pro '•cssisc p o ess The) Ihnufhl it 
pnssihle that piticiits developing i senuii/ilion dcr 
iiiititis were less likcl) to siilfc a s-rious toxie cffec. 
suhscqiienllv 

I xfolislisi. d-imatitis IS tcpsnrted m four easts two 
hem fitil (Rust III P’tx Kivol lOSO) 

Ilcpitu dis'ise w IS found m two f da! c’ses one 
treiicxl with nielhom hid a eentrd lobnlar ns-crosis and 
one dcvc!op*d i fstd hepsto renal ssndromc fo'Uiwins 
ire Itmcnt With metlioin troxidone md plrniiionc (1 ess 
ft III lusii) Riiskm (19 IS) s’ltes tint methom nnd 
troxidone arc hoili pitcntnll) toxic nnd tint loth arc 
related to the toxic suhstnntC phcnslclhslhsdanto n 
combined ii c of the drugs is th rcforc dmtcrotis 

Present IiiscsIiKnlion 

Cases were scl-eicd for nictho n treument onis after 
other remedies hnd been proved inclTcctivc in full 
lolentcd dosnie Pnticnts sulTcrini from petit nnl 
were not given methom ns published results were so 
uniforml) diseourni ini Alloeellicr 4] pitients we'c 
tre lies), hut onlv 2) (l) femde 11 mile) were con 
sidtied Miiinhic for nssessni-nt the others cither faded 
to tdc the driie retululs ur omitted to keep adcqi ite 
records of the numbers of their iltieVs The nveriec 
me w IS no the voiingcst heme 10 venrs old 

A ifctnded history w s taken in order to determine the 
type of cpdcpsv iiul c-ircful reference was nnde to 
previous dnq sensitivity or other form of altcrey I re it 
ment vv IS iisiidly hei un with 0 1 g twice daily this 
heim mere ised hv Oil a day at wecklv or foriniilitl' 
intervals until the neeessary amount was hcine tiken 

The number of altieks ami the tvpe were recorded 
It each intciview the frequency heiiu 1 iter comp ired 
with that before metlioin therapy nnd improvement 
being cdculated on i percent ue basis thus 

wen ' c number o f nuaeks n m onit i after irc a imcnl ^ gT 
nvcrai c number n month ticfore irealment J 

Some rliflicultv vv is experienced m obtaining exact 
ligurcs of both mcidtnce ind type of fit as most of the 
patients suffering from major epdepsv hnd "warnings 
or minor psychoniolor phcnomeni, in addition to attacks 
of grind md nnd tended to neglect the smaller attacks 
in making llicir report Similarly patients with psvcho 
motor epilepsy were not always conscious of thcir 
attacks or could not be persuaded to keep a list of 
them other than in thcir heads The results arc there 
fore onlv approximate 



Jan 13 1951 


METHOIN IN TREATMENT OF EPILEPSY 


BRITISH 

Medical Journal 


65 


Table I —Results of Treatment 


Case 

No 

Sex 
and Ag 

Yypc of 
Epilepsy 

Duntion of 
Methoin 
TrcTtment 
(Monihs) 

NTain 
icnance 
Dosice 
(G /Day) 

Result 
(P rcuntace 
Improve 
ment) 

1 

F 

Major 

4 

0 0 

70 

■5 

h 40 


7 

2 1 

No change 

3 

r 46 


10 

09 

70 

4 

r >6 


r 

0 8 

ino 


F 29 


9 

09 

90 

6 

M 35 



09 

No change 

7 

Nt 24 


4 

1 2 

50 

8 

1 M 30 


4 

09 

50 

9 

1 M 33 


3 

0 3 

No change 

10 

M 25 


5 

1 2 

60 

U 

r 24 

Major and 

7 

1 1 2 

70+50 



psycbomoior 




\2 

r 48 ' 


8 

00 

50 4- no change 

U 

M 24 , 


4 

09 

50 +50 

14 

M24 j 


2 

06 

No change + 






no change 

IS 

M 19 

Major and focal 

5 

09 

100+50 



sensory 




16 

F 45 

Psydioinotof 

9 

06 

80 

17 

F 27 



1 5 

Sf tht 

18 

F 41 


7 

09 

No change 

19 

F 10 


3 

0 \ 


20 

F 23 


6 

06 

50 

21 

F ^2 


9 

02 

100 

22 

M 31 


7 

09 

95 

23 

M 21 


10 

1 2 

60 

24 

M 26 


10 

09 

80 


Results 

The results are shown in Table I The degree of 
response to treatment has been divided into three 
(Table 111 much improved indicating a 70% or more 
reduction in the trc'^uency of attacks improved a 
50-70% reduction and no change if less than a 50% 
reduction 


Taclc U —Do rcc of Response to Treatment 


1 

Much Improved j 

Improved 

No Change 

Major epilepsy | 

Psychomotor epilepsy i 

40 

1 

33/ 

1 "" 

27/ 

1 39/ 


It will be seen that best results were obtained with 
cases of grand mil but even so they are less impressive 
than most of those reported in the literature It is pos 
sible that selection is to some extent the cause of this 
the cases were chosen from amongst a large number of 
epileptics the bulk of whom had been attending hospital 
for some years Thus there had been every opportunity 
for a trial of control by other means and only those 
in obvious need of something better were given methoin 
A further point is that a certain number of patients, 
although their attacks were not fully controlled by 
methoin stated that the fits were shorter m duration 
and milder in degree, or that a larger proportion of 
them did not progress beyond the aura stage 

lUustrahvc Cases of Successful Treatment with McUioin 
Cfljc 4— A woman aged 26 developed major and minor 
epilepsy at ihe age of 10 There was no significant past 
or family history and no abnormal signs were observed on 
examination She was an unstable person much upset by 
her attacks and had twice attempted suicide With pheny 
torn 0 5 g a day and phenobarbitone attacks were not 
controlled and she became ataxic With methoin 0 8 g a 
day she was free of attacks and considerably more equable 
in her behaviour 

Cose 15 A man aged 19 of epileptic stock had his first 

attack at the age of 6 months and by the time he was 11 
years old frequent fits were occurring usually preceded by 
paraesthesiae spreading up from the right leg to the right 
There was a left parietal electroencephalographic 
focus but air studies were normal Before methoin treat 
ment he was experiencing one to three major convulsions 
a week with also frequent abortive sensory attacks Pheno 


barbitone 4 gr (0 26 g) with phenjtoin 6 gr (0 4 g) dailj 
was ineffective and caused ataxia and severe acne With 
methoin 0 9 g a day and devlro amphetamine 20 mg i 
dav no further major attacks occurred and focal sensory 
attacks were reduced by half His behaviour vvhich for 
some years had been a,,gressive and sometimes violent was 
not improved 

Case 21 — A woman aged 22 first developed cpi.epsy at 
Ihe age of 10 the attacks then consisting of sudden nausea 
a bad smell at the back of her nose and clouded conscious 
ness In later years she had had up to eit,ht attacks a 
month of an epigastric aura followed by pallor semi 
purposive hand movements and sometimes complete 
amnesia At times attacks were followed by an mdescrib 
ably bit'er taste but there were no convii'sions No abnor 
mal neurolocical signs were found but there was a right 
anterior temporal electroencephalographic focus Pheno 
barbitone phcnytoin and troxidonc were all ineffective but 
only one attack occurred after methoin was given and com 
plete control has been maintained with 02 g a dav Her 
eosinophil count rose to 20°' during the fourth month of 
treatn ent but she was at that time suffering from a 
r“curience of hay fever 

Case 24 — A man aged 26 was knocked out in a boxing 
match and had his first uncinate attack four weeks later 
He was at that time drinking rather heavily Since then 
he has conlinued to have attacks associated with a sweet 
taste a sensation of dem vii and hp smacking He can 
continue wor* mg or speaking during an attack but usually 
checks his work afterwards to ensure that no mistake has 
been made Pbenvtom could not be increased beyond 06 g 
a day but with methoin 09 g a day there is almost full 
control 

In Cases 21 and 24 methoin exerted its effect rapidly 
and it has been noticeable also in other cases of the 
series that control was achieved early in those respond 
mg to treatm“nt while in those failing to respond large 
doses were little more effective than small 

Cases Not Responding to Methoin 
Cose 2 — A woman aged 40 developed epilepsy at the age 
of 19 the day after her first child was born There was no 
family history of epilepsy or any neurological abnormality 
on examination The atlacks have not been adequately con 
trolled by pheny torn or by methoin 21 g a day and the 
two drills given togelher are not more effective 
Case 12 — A woman developed major epilepsy when aged 
21 Now at the age of 4S she has up to 12 attacks a week 
and there is severe deterioration of personality Complete 
investigation including air studies has shown no gross 
abnorn ality Some of her present attacks are undoubtedly 
hysterical though nearly all are associated with urinary 
incontinence With methoin the grand mal attacks are 
possibly less frequent but improvement is minimal 
Case /7— This patient a woman aged 27 weighed 13 lb 
(5 9 kg) at birth and was cyanosed dunng the first week of 
life She developed normally however until the age of 8 
when a generalized convulsion occurred Since then she 
has continued to suffer occasional grand mal attacks but ■ 
now has mainly psychomotor episodes usually several each 
day In them an epigastric aura is followed by a desire to 
run away and then masticatory movements occur she may 
rub her hands together and is sometimes incontinent She 
cannot speak during an attack A ray examination revealed 
a small calcified area in the left temporal lobe and a slow 
wave electroencephalographic focus was present m the same 
site Phenobarbitone phenytoin or methoin up to 1 S g 
a day has not materially influenced the attack rate 

Electroencephalographic Changes 
Little (1949) studied the effect of methoin on the 
electroencephalogram (EEG) m 26 patients In 62% 
an increase in fast activity occurred and in 58% alpha 


MIlllOIN IN IKLAIMIM 01 I I'll Il'S^ 


f’fMl H 


cf.'jAN n 1911 

.ictiMlv was dtcrciscci Willi conliriiicd dosui. ihcsc 
cITl’cIs bccnnit more pronounced iliou[li llurt w is no 
torrchlion bclivtcn the CI'Ci cit inj t' md the then 
pctilic response. rcKirniin and Victoioll (|9)9) found 
thill in some of their cases the nlpln lelisits hceinic 
\cr\ rt!,ulir, but tlic\ likewise obsened no eorrclilion 
belwe n the IZ I G pillcrn mil the tlinie il si ite I) reel 
ind /iskind (1910) si iled III it nicllioin led to in iiieri. isc 
in fist ictisils in the I LG iiul stressed its likeness 
to the barbitur ile-s in this resp-et 

In the present scries the I I Ci cbm cs were sm bed 
in 18 eases In II there w is m mere ise in fist (20e's) 
aelisiij, sometimes lo a ni irked cslent this did not 
seem to dcp.nd on the diirition of Ircalmenl Ihoiijh It 
disippeared rapidh in one cisc after wilbdnwal of 
mellioin 

III en,ht cises i tioiiecahle clfcet w is the dcselopmcnt 
oi 1 uniform imp'ilude of all the frequencies In some 
the I LG bee imc siril iiu Ij reriilar in ippear inec par 
ticiilirl) so when f> c/s lelisiti w is prominent in the 
record llic nndini is presum ibl\ rel ited to the tej iiI ir 
alphi aclivils reparicel bs Pcllerman Ihouph in the 
present scries ihis frctjiienes w is nril ilfcelid more than 
others 

\ deeieisc m slow wave actisits w is seen in three 
CIS s ill of wbieli ilso desclopeU the inerea<eil rein 
I irils of pattern 

There w is no eorrclation between the 1 I G ebintes 
and the clinic il state This confirms pres ions reports 
but IS none the less surprisuij in sicw of the decree of 
chince sometimes produeed bs mcthoin I he effect of 
barbitiirites is to some extent eompirible in thii fast 
actisitj m IS occur dunne Iq lit sedition hut mis ilso 
persist durinj. conn from barbiturate poisonmr I'os 
stbls methoin ind the barbitunies base this effcst in 
common because of their related chemieal structure is 
Bercel and Zisl ind siq i est but it se ms th it the cb inpes 
are not related to their tberipeutic elfcet 

*9 

IMethoiii loMclts 

In order to iserl toxic re iclions so far as possible 
methoin ssas started in sm ill doses (0 1 ( tssice dills) 
and griduill> mere iscd sshiKI prtsioiislj iidministcred 
drugs sserc progrcssiselj ssiihlield Plienobirbilonc 
hosvescr ssas usualls stopped (|iiickls owing to the 
soporific elfcet of methoin 

A strict system of control ss is used regulir blood 
counts ind visits being enforced b> gisiiq onij a limned 
siippl} of libicts Patients ssere told to bessare of sore 
thro Us feser skin rishes, m il use ind spontaneous 
bruising I hc> svere instructed to report anj such ill 
clfccts at once 

Milr/ Toxic C0ecl\ — In b3% of the eases the patients 
complained of drosvsiness svhich in some continued 
throughout the period of trcitment In the m ijority 
small doses of dextro mipbetaminc controlled the symp 
tom fully Other complaints were dizziness indiccstion 
headache constipition frigidity ind gam in weight 
The last named occurred m tivo female patients to ii 
quite marked degree Gum hypertrophy and itaxia— 
commonly occurring with phenytoin— -were not seen 
One patient h id had acne before treatment svith methoin 
and this became worse A relative lymphocytbsis with 
or without cosmophilia occiiircd in eight piiicnis and 
It may be of some sigmficanee that four of these gave 
a history of some form of allergic reaction m the past 


Iiri/i lltitiiiiitn — An leiilc febrile rcaelion wilh mor 
hilliform risli o eiirreal in five pili nis (21 ) -two 

occurred duriiij the first weef of ircumcni two in the 
first month, ind one m tlie fourth month One of thrve 
hid hiitl in iiltiek of tirlicarn in childhond one hul 
bid tnf mtiU ccJ'cmi mil ahn develop d a r I'li with 
phcnyloin thiil not wuh troxidonc) and one develop d 
I rtsh with iroMilone two did not [ive n liuiorv of 
prcviouv scnvilivity two piticnlv noi included in the 
scries il'o dcvclop-d rashes one had had nctllcrash 
once as 1 ebild and the other Ind suffered from 
U ijniiid s disc ISC of the linecrs 
Il does >ccm the cforc tli it patients with a hiUnrv ol 
previous srnsituitv should (c obverved elo'clj for a 
simil ir re prmvc to nitthom pulicuhrlv durmt tbccirlv 
weets ol tteiimcm In all these patients mcthoin "is 
tempor iril) stopped, hul was pradinlH resumed with 
out til cffcet except III the e isc repo. led below 

Severe {{rirthmv 

I here weic llircr severe rcielionv one Icrniiinting 
fit ills 

Cur tv — Tlilv patirial jiiffered from frequent and vvere 
pUeliimio or ilnck> and hul fad d In revpeu’d to troviJoa; 
or lo phca)iori \Siih ihc Ijller d up a severe e'ernea Mis 
proptevvinp niniovt lo rvfohvlion (s,.euricd and w„v vtdl 
evident when n clliom w is vl iried in «a ill doses Tt- 
rash revolved ssinf.clorib, hni mclhoin c'lilj nol be 
lonlimi-d owing lo a propresvive ilcgfc of leu open a 
Another piticnl (nol ii vliid'd in die senes) was la) lip 
12 I of niclhom a day in hiv fourth monih of ire-'intn 
when he compliincd of nnlitve and fili,iie The cervical 
Ivniph nod s wire cnlargrd and there "as a p-tcvhnl crop 
Ifon over Ihe slioiik'erv Die real blood cell an I p'lle! I 
counts were nornnl hul llierc aov i relative Ivmphiv-yiosis 
of IS After iiielhoin tnd le-n stopped the rash subsided 
and die hlooil piclurc Kkaiiic iiorniaf 

( asf 16 s 

A vvomm ajed ep first had epilepsy ii puberty with atlicks 
rcvcnibhni fainl After sever il scars dnirn il and nociiimal 
prand nul developed bid b'c mae infrequent dtirm., ific hvi 
five years when her mam complaint was of ilistrcsvinc 
pvychoinotor macks occurring in senes She had no si,,niri 
cant pisl history hul dicre wav i hiviory of cpilepvv in die 
familv Nciiroloiual cx iiiainalion revealed no ihnormahlv 
On October 26 ft lb mcthoin 02 g daih was viarlfJ 
blit the palicnl slopped taking the lablcls four days later 
ficcuise of a dazed feclinc, this hemp followed m two davs 
by naal live and a morbillifi'raa rash On November 9 the 
driip vvav resumed and was pndiially increased lo 06 g a 
day This dosaic controlled her iltacks well ind ssidiotil ill 
elfcet except for ilrovssmess sshich responded lo dextro 
implicl inline 

On Jaiuiiry II 1910 die pilicnl ss is sstll but complained 
of II gun in Weight On Marcli It slic compliined of sore 
ness inside Ihe moulh but there was no apparent iikcrilion 
mil the blood coiml w is normal 
When seen on June 26 she was qmlc well but on the 
night of June 30 she complained of ulceration of the mouth 
and diflicully m sw diossmg The next diy n blood cotinl 
It another hospital rescaled 700 vshite cells per c nun all 
bcinc Iviaapliocytcs Slie was admillcd lo dial bospiial and 
cxamin ilion showed haemorrhagic iilceraiion of the gums 
bruising on the limbs and n posilive loiirni piel lesi 1 resh 
blood Ir insfiisions penicillin mil aurcoincm were 
given mrl die coiiclMion of her moulh laaproveel I aler 
hovsever severe menorrlngia and a higli kmpcratnre 
developed these continuing until her dcidi on July 9 
Serial blood examinations revelled a persisimg complete 
agranideieytosis with seintv oi abvent blood plilctels 



Jan 13 1951 


METHOIN IN TREATMENT OF EPILEPSY 


Brntsu 

Mancjo. Journal 


67 


At necropsy the bone marrow \ as found to be aplastic 
There were generalized \isceral pctechiae and also a recent 
basal subarachnoid haemorrhage 

It IS not known exactly when the blood picture in this 
case became abnormal, as the illness began svhen the 
monthly blood count was due Previous examination 
had not shown any abnormality m particular no lympho 
cytosis or eosmophiha When the patient was admitted, 
however the granulocytopenia was already severe 'She 
therefore developed a fatal aplastic anaemia eight months 
after starting methoin therapy The symptoms were 
rapid in onset though it is possible that significant blood 
changes would have been recognized had more frequent 
examinations been earned out There are however 
practical limits to this procedure 
Abbott and Schwab (1950) suggested that serious toxic 
effects were perhaps less likely to occur in patients 
developing a hypersensitive reaction early in the course 
of treatment, but such was not so in this case It has 
also been maintained (though not specifically with 
methoin) that regular blood examinations are fruitless 
that by the time changes are evident m the peripheral 
blood It IS probably too late to attempt treatment An 
alternative supposition is that blood dyscrasias are of 
sudden onset and therefore not subject to discovery by 
regular counts Abbott and Schwab discounted this 
however, and the safest course must remain that of 
examining the blood as regularly as possible during 
treatment 

Discussion 

As has happened with other new preparations in 
recent years, methoin proves to be a valuable but some- 
times toxic drug This study confirms its usefulness in 
major and also in psychomotor epilepsy and shows that 
dramatic results may sometimes be obtained It is, how- 
ever a drug of definite toxicity, and its use may be fatal 
Clearly methom should be used only when every 
attempt to obtain control by other means has faded 
As beneficial effects usually appear quickly it is better 
not to persist with it in patients who are resistant , on 
the other hand a short therapeutic trial may be made 
with little danger 

If methoin is used certain precautions must be routine 

(1) Instruction of the patient and relatives on its pos- 
sible dangers, with the warning that they must report 
any suspicious symptoms at once The patients own 
doctor ought also to be notified that the drug is in use 

(2) It should not be used in conjunction with other drugs 
likely to cause similar reactions It should not be used 
with troxidone though a number of resistant cases seem 
to demand this very combination (3) The patient must 
be seen and blood examinations earned out regularly 
throughout the period of treatment 

Summary 

The results of methoin treatment in 24 cases of major 
and psychomotor epilepsy are described A reduction of 
70% or more in fits occurred in 40% of major epilepsy 
cases and m 31% of patients with psychomotor epilepsy 
Details of EEG changes due to the drug are given 
Toxic effects including a fatal aplastic anaemia in one 
case are described 

The value and limitations of methoin are discussed 

ft IS a pleasure to record the help of Dr Denis Hill ai whose 
suggestion the Inal was undertaken 1 am also indebted to 
Dr T V Mendelsohn for his detailed report oa the fatal case 

C 


and to the Department of Clinical Prlhology at the Maudsley 
Hospital for carrying out ihe large number of routine blood tests 

r 

RcFCPCNCES 

Abbott 3 A and Schwab R S (1950) Nch Engl J Med 
242 943 

And R B (1948) Cahf Med 68 141 
Bcrccl N A and Ziskmd E (1950) ElecJrDcnceph & elm 
Neuropil} slol 2 222 

Boiler W (1943) Schlveu rned lEsc/ir 73 699 
FeUerman j L Friedman M D Weil A A and Xhetoroff 
V M (1947) Ohio St med J 43 1251 

and Victoroff V M (1949) Ots rreri S}st 10 355 

and Well A A (1947) Med elm N Amer mi 

Gibbs F A (1947) Ann intern Med 27 548 

Harris T H and Olto J L (1947) Tex Si 1 Med 43 328 

Kozol H L (1946) Amer J Ps}clual 103 154 

(1947) Ass Res nerv ment Dis Proc 26 404 

(1950) Arch Neurol Psychtat Chtcaio 63 235 

Lennox W G (1946) Amer 3 Psycbiat t03 159 
Levy R W Simons D J and Aronson sS (1950) New Engl 
3 Med 242 933 

Little S C (1949) Electroeneeph iS elm Neiirophysiol I 325 
Loscalro A E (I94S) J neri went Dis lOI 537 
-* — (1946) Amer 3 Psychtat 103 157 

(1947) 3 Amer med Ass 135 496 

(1948) Ibid 138 1114 

Ruskm D B (1948) Ibid 137 103 1 


TUBERCULOSIS IN KENYA 

BY 

W S HAYNES, MA. M D 
Medical Officer Colonial Medical SerMce, Ken\a 

t 

I 

Details of the Survey 

A tuberculosis survey of Kenya Colons was made 
between February, 1948, and February, 1949 In 
default of mass miniature radiography the method of 
the survey was limited to tuberculin testing physical 
examination and the examination of sputa It was 
possible to get only a single specimen of sputum from 
each suspect the likeliest looking part of which was 
smeared on a slide, dried, and subsequently examined 
at the Government Laboratory in Nairobi by the Zielil 
Neelsen method The usual methods of physical exam 
■nation were employed, but care was taken to exclude 
all cases except those with definite and persistent signs 
Unequivocal signs of cavitation were taken as a proof 
of tuberculosis bronchial breath sounds and post 
tussic crepitations were, unless there was evidence of 
recent acute infection, classified as suspicious of the 
disease 

Although limited m method the survey was of con 
siderable extent Africans were examined at 34 differ 
ent places chosen as giving a fair sample of the more 
populous parts of the colony In all, 49 812 mtra 
dermal injections of 0 1 ml of 1 in I 000 old tuberculin 
were given, and a reading was obtained 48 hours later 
in 42,492 instances An indurated area more than 
5 mm in diameter palpable 48 hours after the injection, 
was taken as constituting a positive reaction A total 
of 2 889 physical examinations were made, and 1,298 
specimens of sputum were examined for tubercle bacilli 


Control Senes 

Some attempt was made to rule out non specific , 
allergy to old tuberculin which might be supposed to ^ 
occur m the African, prone as he is to helminth and 
protozoal infections Ninety eight hospital patients 
were given an mtradermal injection of 0 1 ml of 5% 



MtOicn Jtn 0 f,n 


6S II, 1951 rUDLRCULOSli IN KCN^A 


{,l\L<.rin broih los,cllitr \Mtli Iht NHiUoux («t I ifty 
four rcicictl to the tiihtrculin anil one of l!i m \Uio<l 
M iiMoiiN test ivsiiltcti in blistcrme re letej to the con 
trol solution with nhit ippeireil to be t tjpicil tuber 
culm re letion I itcr, S9 sehool children ocrc tested 
with old lubeteubn 'tiul it the vime lime oilh m ecimvi- 
lent dose of I* 1> O (I’lrk Disis ind Co I I ort> eiilit 
horns liter 46 showed i re letion to the old ttibeieiihn 
ind “iO to the I’ I’ I) solution 
Oeeiilt lepros\ Ins been sin ested iis ii possible cuisc 
of r ilsL positive liibcieiilm rcietions (d Are) llirl 
1942) In 1 tceent survc) of the colon) Ross tones 
(19 IS) found in iver u e incidence of 10 lepers per 1,000 
of the popiil ition However his liriires bevr no tcli 
tion to the tuberculin sensitiv it) rates of the ■ ime dis 
triets \ sni ill leper colon) it Msimhvvcni on the 
coist, eontiins '4 c i es of f ir idv meed lepios) Ihcse 
were tulKreulm tested ind 29 rcielors were found o' 
St 4' T eonip inbL ipc i roup ot 9)9 of the t-enet 1 
popiil ition of Msimhvvcni rvvc 74s or 62**''^ rcictors 
Of the five non re ictors two vverc f vr ids meed lepto 
mitous e ises ind three hid tuberculoid leprosv 

fills sniih control senes siiRecsts tfiit the tenenf 
results obt lined ire not si; nificinti) ilfccted b) non 
sp'cific reictions (o tuberculin 

Tuberculin Sensltlvilv Kites 
The results of the siirve) ire shown in rabies I and H 


I ible III sliowi the low scnsitisit) rites found by 
Riirrows (1935) amoni the southern Sudanese of the 
II ilir el Ohti/ il province It is here tli it I )lc Cummins 
(1949) in 1902 found no evidence of liibcrculosis 
' amonp the mtiscs cittle ind wild panic 
M lelcnmns (19351 hriires for I’dcstinnn Atabj are 
i|so consider ibl) lower th iii those of the kcn)a sursc) 
He tested II 403 u ban ‘ehool children of 5-13 years 
of ipc ind found I 923 or 16 2 rcictcd to I m I 000 
old tubcreiilin Of 4 u60 rut tl 'ehool children tS4 ot 
13 2 rfiilcd Tile hviircs for children of the 7-12 
>e irs ipe pronp in kcn)i ire 37 5 and 22 1 , respee 
tivcl) (1 ihles I md II list column) 

On the other bind i recent siirscs of th- Gsdd Coist 
h) lodd (19 tS) showed no sirtm ircis but Inth rites 
of tiihcreiilinir ition it ill ipes , tests with rising 
sttcnplln showed n“iiK 100 positive b) adult age 
Hie Soiilb Africm Mines Report (1942 pp 209 206) 
showed tint 72’' of recruits who cime Itoni sirious 
nviivc territories reietcd to I in 5 000 old tubTeuhn 
on cm i-cmcnt it the mines, mil ‘ repcited tests with 
ttronpe: diliitiois would prvsbiblv (isc 90', teictors 
In rnplmd the I’topfut Sursc) ff9f5l records t/nf 
the )oiini idiill popiihtion stii lied shows an incidence 
of tubcreiilm seniiii?ition of the order of S5‘'', for main 
and f'2'u to 94'' fo- (cmilcs In kens i the 
19-25 )cirs eroiip of nibm residence w is 54 7'^ for 
men and 63 4'y lor women (Tihle 1) 


TaiiI I I — Tiihercntiii Sensiii\ ii\ hntes hi S 1 42 Afrit an Main a’ it 947 African f ft < Vr AVi tc it in \(f>nit ri i an 1 Si rohi 
/ cii\a (Ma\ ri i! Uicenit cr I94S \Iiu nuit J m / r^O) LfrlniAnifj 


Ar Orcun j 

1 Malei 1 


le ut t 

1 

' n 1, VI I 

So 

Te tevJ 

1 UtJ 

Ur\ 1 

^ > 

TritfO 

1 HfJ 

V'* 1 

1 Icli 

rod j 

1 

K'n 

1 b' ! 

1 

1 t i 

Nfl 1 


UfHj f I i 

2S 

0 1 

0 

•4 

1 

(1 > 1 

> 1 

.1 

(1 

UJ 

(If 

7 1 

< 0 

10) 

8 

^ 1 

'14 


7 0 

4-0 

143 

''0 ! 

14 0 

1 4 

20 

\r 1 

-A-’ 

40 ; 

MU 

7-U 1 


IW 1 

4 1 

157 


MO 

416 j 

1<6 

1 37 < 

13-18 

-•95 

l>rj 


t-O 

"'O 

{4'4> 

' \ 


1 

19-25 1 

705 

i 

8^7 

tnn 

nv j 

n ) 

> <^3 j 

V> 1 

1 ^ 4 


1 <V7 

1 

>9 4 


20- 1 

7tj 9 1 

111 

1 "'i ! 

! '7 3 

41- 

^ 4 



If 

11 

{ A4 M 

«41 1 

1 A 0 1 

1 3'^ 1 

Mi ni c^ 

3 13. 

1 ^ i 

75 7 

937 

41S 1 

STS 1 

4 O '> 1 

1 1 

l::!! J 

! 6>- 

i 


Tmilc II — TiiherciiUn Sensiii\ll\ Rates hi 17 07S African Stales anil 16 317 African rcnialcs hesufent m S'aliie Resemes 
Kcrmatl ehruar\ 1947 to f ebruars 1949 Sfuntaiix I in I 000) Rural Rates > 


Ale Group 


Malci 

:inni 

1 emnlci 

Unh S: 

No 

Tc5tcd 

Hn 

No 

TeMwl 

1 ««< rs 

1 il 

Ic \cd 

UcJ ikirs^ 

No 


Vo 1 

So 


Under 1 

4-1 

lu 

2*4 

4(6 

7 

1 5 

fe7v) 

17 

! 9 

1-3 

1 418 

73 

5 2 

1 313 

f- 

4 5 

: voi 

U5 

4 S 

4-6 

1 527 

176 

II 5 

1 5-6 

:i5 

14 1 

luM 

391 

1 S 

7-12 

3 J )6 

B74 

21 9 


731 

23 - 

7 Ml 

1 605 


13-18 

3 212 

1 3J2 

41 3 


1 (H»2 

37 6 

5S75 

2 

40 7 

19 25 

1 003 

7U6 

70 4 


10 2 

51 f 

2 >54 

1 7 h 

57 8 

26-40 

2 f38 

2 

«1 5 


1 95\ 

5> > 

5 s 6 

A ItV) 

(9 6 

41- 

2 hoO 

2 345 

h"* 1 


1 1(3 

61 8 

4 741 

3 <05» 

74 2 

All acc7 

17 078 

7 725 

45 

16 313 

# Ml 

J7 7 

1} VDI 

ns7s 

41 6 


There is a close simihrity between these results and 
those recorded by WilcpcKs (1938 p44) who nndc a 
somewhat similar survey of Tinginyiki fifteen years 
I ago His mmy tables cannot be reproduced here The 
Kenva rates are rather higher except for the younger 
age groups This rs also the main difi’ercncc between 
the Kenya findings and those of Matthews (19354 who 
made a survey of Zanzibar Comparison is difficuU in 
this case beiause of the more complicated technique he 
Used 


The kcn)a sursc) demonstrates (he marked differ 
chcc in rcictor ntes between males and females and 
between those living m town and those in country dis 
tticts Kenya m common with other colonics suffers 
from a hek of vitil statistics, and there arc no figures 
of the tuberculosis incidence in the dillcrcnt pirts of 
the colony 11 docs seem likcl) however tint the 
tijbcrciilosis attack rate is higher in the tovvns or at 
Itiast in the two largest, Nairobi and Monibisa, than 
lb most country districts ^ 


I 


































Jan 13, 1951 


TUBERCULOSIS IN KENYA 


BRmsn 

Mcdical Journal 


69 


Table III — Tuberculin Sensilniiy Rates (Burrov-s 1935) in 2 369 Sudanese Males and 1293 Sudanese Females Resident 

111 Balir el Ctiazal Proxince (Old Tuberculin I in 500) 


Age Group 

[ Males 

I Females 

1 Both 5,.xes 

No 

Tested 

1 Reactors 

1 

No 

Tested 

1 Reactors 

No 

Tested 

j Reactors 

1 No 

1 / 

No 

/ 

No 

/ 

0-5 

201 

18 

90 

225 

14 

60 

426 

32 

7 5 

5 10 

^85 

125 

, 21 4 

261 

41 

157 

846 

166 

19 6 

10-^5 

973 

367 

1 37 7 

475 

156 

32 8 

1 448 

523 

36 1 

Over 2^ 

610 

342 

56 1 

332 

136 

41 0 

942 

478 

507 ^ 

All as s 

2 369 

852 

36 0 

1 293 

347 

26 8 

3 662 

1 199 

32 7 


Men often woik for a spell m the towns and 'return 
to their wives in the Reserves when they have earned 
a little money When adult males were tested in the 
Reserves they were asked if they had ever worked in 
Nairobi or Mombasa of the 5 Q07 men tested 3,029 
who answered Yes showed an 83 1% reactor rate, 
while those who answered No gave a 72 3% reactor 
rate 

Disease Incidence 

It vvas not practicable to examine more than a small 
proportion of tuberculin reactors An attempt was 
made to examine all those with chest complaints child 
ren who reacted and their contacts, and contacts of 
suspected cases of the disease, and also to collect a 
specimen of sputum from these people So besides the 
cases missed by physical examination — which, having 
regard to the type of disease the African gets and the 
ease with which the tubercle bacillus is recovered from 
his sputum may be fewer than would be expected in 
European practice — it is probable that some cases of 
tuberculosis escaped examination altogether 

It was found necessary to divide those diagnosed as 
tuberculous into proved ’ and suspected ’ cate 
gories according to the criteria already described The 
number falling into (he former group for all the places 
surveyed averaged 4 6 per 1 000 It is felt that a closer 
approximation of the true state of affairs would be 
reached if both proved and suspected cases are 
combined in which case the average incidence amounts 
to 11 1 per 1 000 The 1948 census gives an African 
population of 5 252,753 If we take the incidence of 
only proved ’ cases found during the survey as an 
average for the whole colony, then there are 24 000 
cases of tuberculosis in Kenya The figure of 1 1 1 per 
I 000 gives a total of 58 000 cases of tuberculosis and 
It IS felt that this IS more likely to approximate to the 
true number 

It IS interesting to find that Wilcocks estimated the 
incidence in Tanganyika as 1 1 55 per 1 000 In Southern 
Sudan Burrows diagnosed tuberculosis in 173 cases, 
which m an estimated population of 156,300 gives an 
incidence of 11 1 per 1,000 In Palestine, MacLennan 
estimated the incidence at 5 per 1,000 

It must be made clear that the Kenya estimate is 
based on the number of cases actually diagnosed among 
the general population examined in the native Reserves 
No account is taken of the few cases lying in the native 
hospitals of the colony Hospital figures give no indica 
tion of the incidence of the disease Although cases of 
bone joint and glandular tuberculosis were seen fairly 
commonly, there is no doubt that pulmonary tuber 
culosis IS by far the most prevalent and most important 
manifestation of the disease in Kenya 

As can be seen from Tables I and II, for the purpose 
of tabulation the sexes are divided and each sex is classi 


fied into eight age groups In comparing the reactor 
rates found in dilferent districts it is necessary to select 
one age group Adult males are often used but as has 
been shown, their reactor rate varies with their experi 
ence of the towns Children in the 7-12 years of age 
group have been chosen here ' Large numbers were 
tested Sexual differentiation in tuberculin sensitivity 
rates, at least is not marked and males and females 
may for this purpose be combined Their peripatetic 
habits are free but local, and when they become infected 
they probably do so within their own district Table IV 
compares the sensitivity rates of this age group by dis 
tncts Tests which were made at various places within 
the same district and tribal area have been combined 
The disease incidence, computed on proved and 
suspected cases found in the whole sample of popu 
lation tested for the corresponding districts, is also 
shown 


Table IV — Incidence of Tuberculosis per I 000 I Pro\ ed and 
Suspecied Cases) in Both Sexes and at All Apes Related 
to Tuberculin Sensiintty in Boili Sexes at Ages 7-12 Years 


District 

Both Sexes 7 

-12 Years 

Both Sexes 

All Ages 

No Tested 

/ Reactors 

Tuberculosis 
Rate(pcrl 000) 

Nairobi and Mombasa 

Urban Rales 
416 

37 5 

— 

Kapkafet(Kip’ugis) 

Rural Riites 
328 

73 

155 

Mben and Ciamberi 

568 

96 

8 5 

Kisii (S Nyanza) y 

582 

10 1 

5 9 

Embu 

1 119 

16 3 

6 1 

Siaya (C Nyanza) 

330 

164 1 

77 

Maragoli fN Nyanza) 

188 

166 

95 

Kaliado (Masaj) 

239 

184 

II 6 

Kangundu (Maebako s) 

725 

22 I 

14 3 

Kenigoya 

697 

2^ 5 

89 

Teiia 

532 

29 9 

84 

Foit Hall 

87 

35 8 



Taveta 

105 

36 2 

16 0 

Likoni Kisaunj and Cham 
gamwe 

367 

36 4 

8 0 

Msambweni 

237 

I 39 1 

9 7 

Kiiui 

714 

1 39 8 

23 5 

All rural areas 

7 151 

22 4 

11 1 


It will be seen that the highest percentage of reactors 
(39 8%) occurs in Kitui The Kitui Reserve is dry and 
infertile (typical groundnut country), and the Wakamba 
livmg there are in a miserable state of poverty They 
suffer from endemic malaria, schistosomiasis, and 
helnunth infestauon They seem to be dirtier and to 
have a greater incidence of scabies than other Africans 
met with on the survey The greatest number of 
proved and suspected ’ cases ,(23 5 per 1 000) vvas 
diagnosed here 

After Kitui the highest reactor rates were found at 
Msambweni, 35 miles south of Mombasa, and at 
Likoni Kisauni and Chamgamwe all on the coast in 
the neighbourhood of Mombasa In these places a com- 
paratively low disease incidence rate of 9 7 and 8 0 per 


y 





70 Jan 13, 195: TUHI RCULOSIS IN KCNVA 


1,000 rcspcclisclj wis founil NcM comi. the colony a 
two principil towns, Nniiobi mil Month isi lor 
vinous rcisons, no cstimitc of disctvc met lence wia 
possible here Africans living in the towns arc usinlly 
at work ind if the) fill sitl either go to hosp t il or, 
in the CISC of pulnion ir> tiibtrculosis more often return 
to their UeservLS I bus dihouth it is Id th tint tuber 
culosis often develops in the tirbinired African it is 
not expected tint i verj huh divcise incii'cncc would 
be found except inioiif the indigenous popu’ ition 
M ileocks (1932) found tint reictor rites and diveise 
ineidence in 1 iiieinviki \ tried in direct propirtion ind 
tint the forniir could be tilen is i me isurc of the 
litter Ibis gencnh/ition is pirtidlj true of Keiiyi 
Obvious discrepincics ire the low sensitivitj rites but 
rclitivelv liigh discise incideni.c found it Kipkitet 
Mberi, ind Ci inibcri— ill remote and rither ivolited 
up countrv ire is while the co ist d districts isexeipli 
(led b\ Msimbvvcni 1 d oni Kisiuni and Clnmj imwc, 
show the reverse tenJcncv with verj hi[ h re letor rites 
and eonip ir itivcl} low discise incidence It is *iii rsted 
th It the (irst phcnoni'-non deno es i recent introduction 
of tuberculosis while the second indicites a more pro 
longed exposure to the discise 

Tvpe of 1 ulicreiilosis Seen In the Afrlcin 
Most obseners ire nj reed tint Africms suffer from 
1 more icutc ind f itil t>pc of tubereiilosis linn 
luropeins Thus \ ini (1937) in in indvsis of 1(100 
consecutiv,. nevropsics in N iirobi found tiibcrcii’ovis 
to b> the c iiise of dc itli in 132 c ises ‘T h* post ti ortem 
findings atw those of i low septic leriii i reseiiibhrii leiiic 
jmlnr> tuberculosis in Curop-in children while 
Wileocks (I93S p 52) finds i prepondernnee of ciscs 
of icutc gdlopinr consumption These miivcs he 
midvva> between the completely primitive rices ind our 
rchlively rcsisliiu selves Mine workers on the Kind 
were found to develop an acute form of pumonrj 
tuberculosis ch ir iclerizcd b) gl indulir involvement inJ 
milnrv dissemin ilion (South African Min s Keport 
1932, p 25S) Post mortem evidence from Mu leo Ill's 
pitil Ugiildi le ids Davies (1947 1 ) to suppose 111 it 
pulmoniry tuberculosis as met with m Ug indi is 
rarely of the adult reinfection t>pc but in the v isl 
majority of cases is the result of primary infection Icid 
ing to the development of a glion focus ind this does 
not heal but leads to dissemination of the infection with 
resulting death 

Gclfand (1944) writing of the Southern Rhodesim 
native siys he has never seen an African recover from 
pulmonary tuberculosis and D ivies (1947b) quotes 
Trowcll as having in equally depressing experience in 
Uganda Oswald (1946) hid the opportunity of study 
mg the disease in 416 Africans who developed pulmon 
‘ ary tuberculosis while serving in the Army in the Mcdi 
terrancan area Forty seven cases which came to 
necropsy had a history of illness for an average of 5 4 
months He describes the usual destructive caseous 
pneumonic lesions and found glandular cn'argcmcnt 
m 96% of these cases Caseation was present in 66% 
and in 92% the mediastinal glands were involved 
The contrary opinion, that a chronic form of pulmon 
ary tuberculosis is not rare in Africans is less usually 
expressed but Wilson (1928) believed it true of Kenya, 
and Burrows (1935) of the Sudan Fennel (I932i writes 
of cases in the Biitterworth area of South Africa 
Many were fairly chronic lasting at least three years 


PtmiH 

MrmcjiL I'M fN t 

and over, showing that the natives, under their own 
conditions hid a considerable power of resistance 
Allan (1932) whomidcnn cviciisivc survev of the native 
Reserves in South Africa found that most of the cases 
With pulmon It) tuberculosis were more or less 
chronic 

It will be noticed that pathologists basing their 
opinion on necropsy reports, arc igrecil on the extreme 
iciitcncsv and short duration of pulttioriary tuberculosis 
in Afric ins Clinici ins and held vvor) ers tend to be less 
p-svimistic and some believe that the consumptive 
African may survive some years under the condiliuns 
he IS used to TTic difierencc is to b- explained bv the 
extreme degree of selection in the material avaihbl to 
the pathologists Cases of pulmoniry tiibcrculovis arc 
not popular in overcrowded native liovp l iK, ficililics 
for ifcilint them arc not usuallv avail ibe and proper 
acconiniod ilion is lacking Die sicl Afru-an iv iinvvill 
ing to spend long periods in liovpiial cspectdly when 
no nctisc ireitmcnt is being cirricd out ind he fc Is 
little hrnrfil to his h'-alih 1 or this reason only Iho c 
pidnioiiity tiih''rciiIosis subject' who arc too ill to be 
thscliaiged or to drat, tbemvclvcs from hospit il arc 1 kcly 
to die Oicrc Sui.)i cases comp isc the post mo tern 
niiterial of the pathologists 

During the Kenya stirs cy a definite history was 
obtained from 70 of the 106 prosed cases of pj'mon 
iry tuberculosis diagnosed No great reliance can be 
pi iced on this but the as crate duration of the disease 
was given ns 19 months In four cases some ptou' of 
the Icnith of history was forthcoming for these ri'n 
bill been disebarjed from hospitals ns proved cases of 
pulmoniry tiibcrculovis TTicir lustorivs sscrc of 53, 
525 IS and 37 months 

TTic scry fict tbit infection ns demonstrated by the 
tuberculin test is so wul-vprcad woii'd seem to faviur 
(he existence of it least some chronic infect out perambu 
latory ciscs For bow could the mijorits of the popu 
hlion be infected by those iciiIc pnciimoaic ciscs 
prostritcd by lox icmia and dying iftcr a fevs montlis 
which the patholoeists describe 

TTic f icl til It cases of pneumonic plitliisis do so badly 
vsith collapse therapy would also seem to indicate that 
such cases arc not vvilboiil exception For Disics (1946) 
after 20 years svork at Kibonqoto m Tanganvika 
reports in cncoiinging survisal rate in 560 cases of 
pulmonary lubcrculosis treated ssitli artificial pneiimo 
thorax and aneilliry mcisurcs 12% alisc after 3 years 
and 22% after 10 

Tlicsc obscrsations sliovs that the fulminating type of 
disease ilcscribcd by the pathologists as resemb ing 
progrcssisc primiry infection is not without exception 
Anyone who his had experience of tuberculosis in Fast 
Africa would agree that its usual course is much shorter 
and more acute than that seen in Furopcan practice 

The Kenya survey and indeed every tuberculin test 
iijg survey made in Africa in recent vears shovvsDaviess 
(1947a) assertion that the African never recovers from 
Ills primary tuberculous infection to be wrong The 
maiority of adult Africms have been infected and show 
no evidence of the disease So fir as this factor is con 
cerned the state of affairs is like that in Furopc How- 
ever It IS prob ible that adult primary infection not 
infrequently Ic ids to progressive tuberculosis in Africans 
when they arc exposed to a tuberculous cnvironnunt 
Stotts (1950) investigation at Nakuru giol where tiibLi 
culosis IS rife shows that an undue mortality falls on 



Jan 13, 1951 


TUBERCULOSIS IN KENYA 


Britisu 

Midical Journal 


71 


Ihe small group who enter the gaol tuberculin negative 
It IS Iihely that uninfected adult Africans, coming from 
their reserves to work in the towns, also are hable to 
develop progfessive primary disease 

In view of the high tuberculin sensitivity rates found 
<■ all over the colony, it hardly seems possible to explain 
the extremely severe and fatal type of tuberculosis which 
IS most commonly seen solely m terms of adult pro 
gressive primary tuberculosis, although” this might m 
part account for the observation that tuberculosis in 
Africa tends to be more severe in the towns than m the 
reserves i 

It IS usually supposed that the chronic fibre caseous 
type of disease commonly seen in Europe results from 
a partial immunity conferred by childhood mfection 
Many children have been found to be tuberculin sensi 
live in Kenya, but only a few adults develop the chronic 
apical disease of Europe It would seem that a healed 
primary infection may not have the same immunizing 
power in the African as is usually ascribed to it in the 
case of the European This contention is supported by 
the findings of the South African Mines Report (1932, 
p 97) on tuberculosis among African gold miners on 
the Rand These Africans were graded into four cate 
gories on engagement at the mines, according to their 
reactions to serial tuberculin tests — positive plus, 
ordinary positive, weakly positive and negative ’ 

I reactors It was subsequently found that the incidence 
of tuberculosis was 2 9 per 1,000 for negative 
reactors, 4 5 per 1 000 for weakly positive,’ 6 5 per 
1 000 for ordinary positive, ’ and 10 3 per 1,000 for 
positive plus reactors In South Africa Professor 
Lyle Cummins (1932) found that ‘ fully 50% of healthy 
natives arriving at Johannesburg were capable of react- 
ing to 1 in 1 000 000 tuberculin dilution, whereas m 
tests carried out by me on clinically non tuberculous 
adults in Wales only 25 % were found to react posiUvely 
to a dilution of 1 m 100 000 In Kenya serial tuber- 
culin testing was not done but of 37 460 Mantoux tests 
made on the general population 1,969 showed vesicula- 
tion — that is, 5 3% of the total tested and II 8% of all 
reactors In England dArcy Hart (1932) found less 
than 1% of the total tested and 2 3% of the positive 
results vesiculated Wilcocks (1938, p 31) found that 
in Tanganyika comparable percentage were 3 2% 
and 6 1 % 

It does appear therefore that Africans are more 
sensitive to tuberculin than are Europeans, and it seems 
likely that this factor is associated with the distmcUve 
type of disease they are liable to get 

If the same significance attaches to the tuberculin 
' test in Africans as it does in Europeans— and there is 
no reason for believing otherwise — then it seems that 
both races are able to sustain a primary infection almost 
equally Well This observation is of fundamental 
importance for racial immunity is usually thought 
to condition this ability May it not be rather that 
racial immumty is a reflection of the power, not of 
sustaining the primary infection but to form antibodies 
to the invader and so modify an aftercoming infection ’ 
It IS not pertinent to this thesis whether the infection be 
endogenous or exogenous 

The African when infected develops a high degree 
of allergy to tuberculo protein as demonstrated by his 
extreme sensitivity to tuberculin but little concomitant 
immunity as exemplified by the acute infantile type of 
disease to which he is prone The hyperallergic state 


renders him hable to an acute and destructive type of 
tuberculosis on reinfection, while lack of immunity 
deprives him of the power of confining the lesion, as in 
European phthisis but leaves a secondary infection 
unmodified except by purely allergic factors so that it 
often assumes the characteristics which we arg accus 
tomeck to attribute to progressive primary disease m 
Europeans 

Summary 

A description is given of a tuberculin testing survey in 
Kenya , 

A small control series did not show any significant 
tendency for non specific Tactors to interfere with the 
results 

The sensitivity rates were found to be high in Kenya 
and are compared with those of other surveys ^ 

A greater percentage of men than women were found to 
be sensitive to tuberculin Urban residence was associated 
with an increased sensitivity rate 
The disease incidence is thought to be about 1 1 cases per 
1 000 If this IS correct there are 58 000 cases of tubercu- 
losis outside the hospitals m Kenya 

A degree of correlation is demonstrated between the 
reactor rate and the disease incidence in the various districts 
surveyed Exceptions are discussed 

Reasons are given for supposing that although the acute 
fulminating type of tuberculosis resembling a progressive 
primary infection is undoubtedly very common in Kenya 
It IS not without exception especially in the rural areas 
An attempt is made to correlate high tuberculin allergy 
with the African type of pulm6nary tuberculosis 

I am indebted to the Director of Medics)! Services Kenya 
Colony tor permission to publish this precis of my report to him 
on a tuberculosis suney of that colony 

' References 

Allan P (1932) Piibl S Afr hut med Res S 247 , 

Burrows Sydney M (1935) Tubercle 16 Suppl P 20 
Cummins S Lyle (1932) PubI S Afr Inst nied Res 5 260 

(1939) Prinutne Tuberculosis London 

Davies H N (1946) E Afr med 7 23 194 
Davies 3 N P (1947a) Ibid 24 357 358 

(1947b) Ibid 24 180 

Fennel (1932) Publ S Afr Inst ' med Res 5 209 
Gelfand M (1944) The Sick African p 184 Capetown 
Hart P dArcy (1932) The Value of Tubcrculm Tests in 
Man p 14 Spec Rep Ser med Res Coun Loud 
No 164 , ' 

Innes J Ross (1948) Unpublished Report No 7 to the Director 
of Medical Services Kenya December 7 
MacLennan N M (1935) Tuberculosis in Palesime p 22 
Palestine Government Pub July 20 
Matthews R J (1935) Tubercle 16 Suppl p 64 
Oswald N C (1946) Thorax 1 100 

Prophit Survey (1948) Tuberculosis in Youne Adults p 30 
Report on Prophit Tuberculosis Survey 1935-44 London 
South African Mines Report (1932) Publ S Afr Inst med Res 
S 

Stolt H (1950) E Afr med J 27 379 
Todd K W (1948) Tubercle 29 200 
Vint F W (1937) E Afr med J 13 332 
Wilcocks Charles (1932) Ibid 9 88 

(1938) Tuberculosis in Tanganyika Territory Government 

Printer Dar es Salaam 
Wilson C J (1928) E Afr med J 4 296 


During the period October 15 to November 6 1950 570 
U S Navy medical reserve officers arrived at Brooke Army 
Medical Centre San Antonio Texas for assignment to 
active duty with the Army These officers were interviewed 
by a staff officer from the office of the Surgeon General 
for professional classification and assignment They were 
given one days processing in connexion with their 
entrance on active duty and received a three day intensive 
orientation course before leaving for their units 



72 Jan IJ l'»51 


AUULOMYCIN IN SUPl'URAllVC I UROMHOPIU LlilllS 


i-rutHix, 


SUPI’URAl IVi: THROMBOIMH 1 RITIS 
IRFAIID WIIII AljRIOMVClN 

in 

I) MiicG JACKSON, I RCS 
{I rom the Mit'uiil hetmuh Ctmiii/ lliirnt Unit 
llirmini,haiit Acitdeni //enfilnl) 

Of the \'iiK'ii5 t>pcs of thromhophicbilis tlie infectiom 
mil Aiippiir iti\t t iscs form onh 3'u (Hitler, 19Jt> 
lhe\ in, often f It'll, liouc'cr oninj to tlic development 
of p\ icmi 1 ind nicfist me foci I he followint; t ne of 
ilio fcinor il thiombophlcbitiv is of pirtieiilir interest 
for three reisons (1) the proj nosis wns nude worse 
b> the infcetini, ori mism beitip a penicillin resist int 
Sltiph\loioi.Lii\ aiiri IIS (2) i misfike wis probahK nude 
in discontmiiinp the chemotherip> too cirl>, intl 
(3) a successful reeoscrj w is ncscrthcless obt lined with 
lureomjcin without sem litition proximil to the 
thrombus 


Caso llcport 

A hii> lied 1 sears fell into i tnth of hot wuer and 
received scvldv of his bael thighs and left srm The 
eslcnt of the scilded nrev vns 2-t ' of the lsid> siirfsce 
2 beint V hole shin loss 

On idniivMOn he wis treated for shoe), with R'O ml of 
phsim diirine the first 27 liniin the dressinc «ss done 
seven hours ifter nd itssion md the tncleriolo,ical stubs 
from the s,.sldcd surf ice at tint time }.tcw niicroso-ci onlv 
Svsteinie penicillin vv is begun with an initial dose of 2*0 000 
units and tlivn ^0 000 units four hotirl) f urthcr swabs tin 
the fourth dij showed the presence of iit ph aureus and 
Pseutlonionns psoounea 


r uncos* YC I 
soour. c'ilV 


g 106 
5 104 
5 102), 
Z lOG 
98 


n 


uj'*/ (r?? 

lig 




''.■•yAjA-Mi 


lO 20 30 40 50 

DAYS SINCE INJURY 


AUnCOMYCIN 
500MG daily 


iaoti 


g 106^ 
!? 104- 
£ lOP. 
2 lOO 
m 98, 


cca 

u-tr 


aa 
-c S 

83 


A 


O 

cr 

< 

X 

8 

a 


VAsAsr^- ^i) Arvijwc- AVv w 
60 70 80 90 lOO 


70 

DAYS SINCE INJURY 


Temperature chart durmfi the treatment of thrombophlebitis wit 
aurcomycm 


Onset <)/ Thtnml opMelntts — On the luth day the childs 
h icinoi lohin was (>')' and a bottle of blood wav given 
after tutting down on the rifhl (reat saphenoiiv vein at Ih 
mile I our digs laicr hiv temp- atiire rme to 105 P 
(•ill 6 C ) (sec ( hart) ind the pulse to IfiO the right calf 
was prowl) swollen hoi and tender and die drip ireu on 
was inllainrd Sgslcmic pcnieillin w iv incrct-ed to IfOOOO 
units siv huHiIy and a eout’C of sulphadi itidine wav s arled 
(2 S g mill illy then 0 * ( four hourl)) On ih* folloA n: 
dav (I3lh) I small abscess was incised over the upper end 
of the tibia and from the piiv a pi re p/ovili if p-n cillir 
resistant Staph aureus was (town The local infiimmatci'a 
lesion subsided during the nevl three days but as the 
Icmperaiiire remained at 102 P (JS*) P) and It - ptilic 
at IfO aiirco iiyein was h'pun on the lOth da) (37* rag 
mi lall) then 125 mg su hourl)) On the 19 h day tender 
indurated ihtumhsa cJ l p'tfivial veins appeared on Ih' 
m'dial 81 le of the tight Ihiih cMcndirg to wiilm 2 in 
(5 crrD of the pirction wi h the femoral sein v hi h was 
not palpable I be tontae of sulp'udiiridine was stopp'd 
nfier i mini dosape of 21 5 r the white cell count b'lng 
5 0*0 per emn 

Opera Ian on the I emorcl I eln—On the 21s' day it was 
decid'd to lie the titbt saplcnois vein since the local signs 
Jiigicvted invoivcin'nl of ibc sup' fi-ial veins only At 
operation the sapbenouv ve n and tis traliitatics were 
collapseil and e iipi) but the femoral vein wav foiird to 
fie IbfomKaved ilioiigb il Itad t'cn impalpable II was 
op'ned and some n* the vellow thrombus smeired I'n a 
slide and lalen for tullurc the cxlerral ihac vein was 
not ctplorcd and vv^v too small for an attempt at sucbing 
out the clot The fc noral vein was li'd hut He ihronbus 
w IS pilpiblc at least < la (1 25 cm) p vivimal to the hp 
tiire Hie sni'ar showed well stained Oram positive cocci 
and the culture yrew penicillin tesivtant SiapI aureus 

Ithx'd cultures laLcn on the day of ep-etation nnd the 
next two daw (21st 22nd and ^itd) xvere all sterile after 
‘S hours An operation to tic the iliac xein aKavc th' 
thronihiis was decided against i eciusc the childs conji'ion 
was improving the orpinism was known to Ic sensitive to 
rviircomycin blood cultures were n'^^tive and there was no 
sign of m-iisialic sp eid liy the 2-llh vl-av eight daw after 
aureoniycin was Slatted his clinical condition was much 
heller and the Sirph aureus had entirely disappeared from 
the siald On the 33rd day penicillin and auteomycin were 
sloppcvl after total dosages of 24 If 0 000 units and 9 375 mg 
respectively 

Shin praliinp Operniioris — Tile graniilalinp areas "ere 
covered with split skm grafts on the 27th and 39ih davs 
and by the 4Sth day bcahng was complete and there was 
no oedema of the leg or any pilpahlc veins 

Pirst Iseciirrense o/ Psrexut — Tlircc diw later however, 
the child hcc-inic ill ngam vviih a icmp'ratore swinging 
between 99 nnd 103 8(37 2 nnd 39 4 C) Clinical exanii 
nation and invcvticalionx rev cited no cause so thal after 
three diys a recurrence of the previous infection vv is pre- 
sumed in spite of a sicnie blood cuUiirc and aiiteonaycin 
was rcstirtcd There was n rapid response and the drug 
was discontinued after nine diys (total 4*00 mg) 

irroiid heturrenct o/ Psresla — After a fiirllicr eight days 
Ibc child s temperature acain rose to 102 5 i (39 15 C) 
and agiin it was impossible to confirm Ihc diagnosis A 
fiiribcr cxacerbiiion of the tlironiboplilgbitis was presumed 
nnd a 28 day course of aiirconncm was begun The tempera 
lure became normal m a week and did not rise agiin The 
boy was discliirged at the end of tins course (14000 mg) 
pcrfeclly fit and during the next 10 weeks showed no sign 
of fiirllicr recurrence 


Comment 

The three lines of treatment in general use for this 
condition arc antibiotics proximal ligation of the throm 
bosed xein, and anticoagul int therapy 




Jan 13 1951 


AUREOMYCIN IN SUPPURATI\'E THROMBOPHLEBITIS 


Bamsu 

Medical Journal 


73 


There is no controversj about the use of chemo 
therapy the most powerful drug against the particular 
organism isolated should be given as soon as possible 
m adequate dosage and for a sufficient period The 
recurrence of the clinical picture of sepsis with too early 
cessation of the drug has often been noticed — for 
example, Hyman and Letter, 1944 Lyons (1941) 
reported two consecutive cases of staphylococcal 
cavernous sinus thrombophlebitis treated with sulpha- 
thiazole and heparin with recov ery Each of these cases 
had a bacteriaemia which lasted six and eight days 
respectively and he advised continuing the sulpha- 
thiazole for three months in a dosage sufficient to mam 
tainAhe blood level at 5 mg per 100 ml Schall (1941) 
reported three further cases of staphvlococcal cavernous 
sinus thrombophlebitis successfully treated with sulpha 
thiazole and heparin There is little doubt that if control 
of the pyaemia can be obtained by chemotherapy for a 
sufficient time this is likely to be successful in curing 
the thrombophlebitis For staphylococcal infections the 
antibiotic of choice is now aureomycin (Long 1950) and 
Spink and Yow (1949) have reported five cases of 
staphylococcal bacteriaemia treated with aureomycin, 
with four recoveries 

According to Van Duyn and Van Duyn (1940) the 
idea of trying to stop the spread of infection from a 
diseased vein into the general circulation originated with 
John Hunter in 1793 when he advised putting a com- 
press on the vein just above the suppuration Since 
then and until the development of chemotherapy, the 
mortality of suppurative thrombophlebitis has been pro 
portional to the inaccessibility of the septic focus and 
the difficulty of eradicating it (Rosenow and Brown 
1938) Before the advent of sulphonamides vein liga- 
tion was the only rational therapy but the mortality was 
still high septic thrombophlebitis of the neck for 
example had a mortality of 20-30% even with operation 
(Iglauer 1942) 

The present value of proximal ligation of the throm 
bosed vein is more debatable Kern and Berman (1945) 
reported a case of ilio femoral thrombophlebitis follow 
mg pneumococcal lobar pneumonia empyema, and 
septicaemia which proved resistant to sulphonamides 
and dicoumarol the patient was cured however, after 
ligation of the inferior vena cava above the thrombus 
and a course of penicillin Which one of these pro 
cedures played the major part in the patient s\ recovery 
It was impossible to say, but they felt justified in stating 
that the convalescence was very definitely shortened by 
the surgical intervention and the danger of embolism, 
minor or fatal was eliminated In contrast a case 
described by Kirk (1947) illustrates that proximal liga- 
tion without control of the pyaemia is likely to be 
fatal His case of suppurative ilio femoral thrombo- 
phlebitis due to Aerobactcr cloacae was temporarily 
controlled with streptomycin but drug resistance deve 
loped and when infection spread to the opposite side 
the inferior vena cava was tied In spite of this the 
patient developed septic meningitis on the sixth post 
operative day and died two days later 

In practice few would doubt the wisdom of proximal 
hgation when the vein was easy of access when there 
was, a positive blood culture and when the organism 
was resistant to the drugs available Again there is 
unlikelv to be disagreement m adopting a conservative 
attitude if the site of the proximal end of the thrombus 
IS inaccessible it repeated blood cultures have been nega 
tive if the orgamsm is sensitive to the antibiotic and 


there is serious concomitant disease Between these 
two extremes it may be difficult to come to a decision, 
but the chief indication for vein/ligation is inability to 
control the bacteriaemia with antibiotics 

Anticoagulant therapy is of less importance but as 
It may prevent extension of the thrombus it should be 
given when possible An ^pen wound such as was 
present in the case described is of course an absolute ' 
contraindication It is interesting that both cases 
described by Lyons (1941) developed pulmonary infarcts 
while receiving heparin 

Summary 

A case of suppurative ilio femoral thrombophlebitis arose 
from a transfusion incision infected with penicillin resistant 
Staph aureus and this was treated with aureomycin At 
operation the diagnosis was confirmed but because of the 
organisms sensitivity to aureomycin the repeated negative 
blood cultures and the sustained clinical improvement 
proximal hgation was not performed Failure to give the 
aureomycin for a sufficient penod initially is believed to 
have resulted in two recurrences but after 125 mg had 
been given six hourly for 28 days (total 14 000'mg) the 
condition was finally cured The treatment of suppurative 
thrombophlebitis has been considered brieffy 

References 

Barker N W (19341 Proc Mayo dm 9 191 
Hyman A and Leiter H E (1944) J Mt Sinai Hasp 10 583 
Iglauer S (1942) Arch Otolaryne Chicago 36 381 
Kern H M and Berman E (1945) Amer J Surg 69 120 
Kirk G D (1947) Ibid 73 606 
Long P H (1950) Lanrei I 420 
Lyons C (1941) Ann Surg 113 113 
Rosenow E C and Brown A E (1938) Proc Mayo Chn 
13 89 , 

Schall L A (1941) J Amer mei Ass 117 581 ^ 

Soink W W and Yow E M (1949) Ibid 141 964 v 

Van Duyn E S and Van Duyn J (1940) Ann Surg 112 
294 


Medical Memoranda 


Case of Ovarian Pregnancy 

The occurrence of an ovarian pregnancy is still rare 
enough to excite interest It is estimated to occur in 
0 7-1 % of all ectopic pregnancies In recent years the 
subject has often been reviewed (Isbell and Bacon 
1947 Bolton 1949 Deweese, 1949) and the numbers 
of authentic cases have been \ariously calculated as 
approximately ^0 (Curtis 1941), 52 (Way 1941) and 
50 (Novak 1947) 

Case Report 

A woman aged 21 marned for one month was admitted 
to hospital on October 20 1949 complaining of pain in the 
abdomen Four months before admission (three months 
before marriage) she first had coitus Her next menstrual 
period v.as 14 days late but otherwise normal The follow- 
ing period Nvhich occurred 28 days later was normal She 
then married and engaged in coitus but the menstrual period 
which was imminent did not occur Se\en days after her 
marriage «he sudden!) collapsed in the street and complained 
of dizziness low abdominal pain and vomiting There was 
no vaginal bleeding 

She ^vas admitted to another hospital believed to be 
suffering from acute food poisomng but was discharged 
after three da\s though still complaining of intermittent 
abdominal pain and she sta>ed in bed at home 

A week later a profuse vaginal haemorrhage occurred 
associated with abdominal pain localized to the left side 
Large clots were passed and the bleeding lasted three days 



/ 


74 J^s 13 1951 


MCDICAL MEMORANDA 


c*mTii 

Hr fOkt icr *S4t 


lliL pun slill pcr-iKial Ap ui from nn iniit\ tl ippcndic 
ictonii two jcir\ prmoiiUj slic li id I'ccn ipnlc hcillli) 
Mcnstriiiiion lic( in at 11 and hid hccn quite rend ir wilh 
norm it lo<i'. 

On idmission her icricnl condilmn wn ( ood llie rniiinii^ 
nicmbrincs uerc of nornni colour piihc ')2 temper iliire 
97 8 1 (3fi 5S C) re^pintioin 20 blood prciMirc US/70 
Tlic abdonan iioi diOendcd the w ill moved ftccl> 
the iimbihciiv vvnv not diveolinircd There wm <ili,hl 
Icndernevv in the left due fowl but rirulil) or free Oiiid 
vv tv not detevtcd 1 vnmimtioti per viiirnm vhowed heilth) 
MilvT ind iircthro vofiish inobdc cerviv Ihere wav no 
cni irj,cnicnt of the iiteruv, whah w iv intevertcd but an) 
nttempt to move it eiiived treil pelvic pun /\ tenrler ill 
defined solid nnsv about 2 in cm ) in diameter vvav 
palpable m the pouch of Roupliv ippjtciitl) conlimimiv 
with the left idncvn Ihc ripht appcndaiev were normal 
Per speculum i health) nullipatiuis cervix was seen 
TTic urine was nornni A btoo I count showed leiico 
c)tes 8 100 cr)tbroc>tes tOOOtXX) Incmoplobm 90' 

A tentative dinnovis of a left c..topic pre, nine) was made 
On the sixth d i) after admission a profuse vapinal 
haeniorrha)c occurred with inod-rite pun in the left ibac 
fossa rxplorator) lipirotoii) vv is then decided upon 
Operoiioii — fins w is carried out bj one of us (I Ci ) on 
October 2fi On opcmn\ the aldonen the p'tilonctim was 
normal in colour and no free bleu I w is seen Uterus 
tubes and rii,ltt osar) sscrc ni'rmil in app-irinte TTic 
omentum ssas idlicrcnt to the po tenor as-Cet of the utenis 
and left broad Iq ament li) films ulbesions wliidi separated 
rcidil) rcvc ilin) the left uv irj to ssbicb w is atiaclied 
a miss of blood clot the si/e of a tennis ball /\d)aceni 
loops of idhcrcnt bowel sscrc p-elcd c'll casd) ind the mass 
and about half of tbc os it) wen tcnioved No corpus 
liiteiim w IS seen on the rq-bt ovar) nor was there macro 
scopic csuicnce of endometriosis I be abdomen vsas then 
closed in la)ers 

Cons ilesccncc was uneventful the pilieni was ambulant 
on the fourth di) ind w is discharied on the ninth post 
operative di) Snlpinpotriph) performed on November 26 
showed patenc) of both tubes 
Paihi’loi.ic(il l\<rort (J 12 ) — TIic specimen consists of 
about half of an osar), Uv the free surface of which h 
attached a firm lamin iled ept. shaped mass of blood clot 
4 cm in diameter On the cut surface of the ovar) a 
corpus hilciim of pretinnc) 1 5 cm iii diuiiclcr is visible 
On breaking awa) fragments of blood clot villi ire seen 
m the neighbourhood of the corpus hitcuni and adjatenl 
ovarian tissue No foetus vv is found Sections show 
syncytial misses and chorionic silli emhedded in the 
ovirian tissue and insading the corpus lulciini Man) of 
the vilh ire ahead) deicncratcd The ovariin stroiiii is 
excecdmglj vasculir but no pseudo deeidu il cells arc cvi 
(Jent the ronal li)er is lieisil) infillriled wiiti pol)morphs 
plisma cells and micropliqcs but this reaction is not seen 
elsewhere in the ovar) The liistological picture of the 
corpus liitciini coincides with , ill it of an cirt) pregnane) 
with tbc cenird core oteiipicd b> a recent organiring clot 
There is no evidence of ovirian cndomciriosis 
\Vc vvisti to lliank Professor C Parqulinr Murray for Ills help- 
ful suBgcsiions and for permission lo publish this case and 
Mr D Ilarland for tiis tcclinicn] assistance 


LGvN/rRCSCd MRCPI 


Senior Registrar Department of Gynaecology 
J E Ennis MB B S , 

^ Consutlam Pnlhologist 

Dryburn Hospital 
Durham 


RnfcnpKccs 

Bolton John P (1949) Ohio St med J 45 353 
Curus A H (1941) Stirft Gynec Obstet 72 1039 
Detveese W J (1949) Xfmn Med 32 272 
Isbell N Paul nnd Bacon W B (1947) Amer 3 Obsu 
- ^yucc 54 329 

"’fJe CyimccoloRica) and Obslelrlcal Palholog 
avo Saunders Philadelphia 

Way S (1941) Brli J Obsiei Cynnee 48 473 


Sfranfiulafed eSpifielian Hernia 

Spipclnn herni i occurs ilon" Iqc scniilinar line, iisiially 
ncir the level of Ihc Trcinic lipmicnl II I'cncirilcs the 
broad fiscnl bind b) whicli the intern il oblique and 
tf in vers ills muscles arc inverted iiiio the rccitiv sheath 
but lies tinder Itie aponeurosis of the external oblique 
muscle Ibis tense nponciirosis obveurej /the lumour 
and maV cs it dilhtuU to palpate 1 be bernia has a tough 
rijid neeV. and is often co cred b) a thick U)er of 
extraperiioncil fit 

Casp Kiioi't 

A stout woman aged 65 with a lax p'mhiloiis ahdo"ien 
bad a histur) over cveral yeirs of periodic abdo meal 
distension and voniilinp somtlmi-s sviih rleriis of tie skin 
and typical gall 1 1 idJ-r colic Cholcwyvtce omv was get 
formcil in August I'l 7 Th' gill bladf-r svas small and 
packed ssiih Slones lie torunon duct was free of sion's 
Colic and i ten v were inmcdialel) relieved but tlm atta'ks 
of disicrsiiin md vo nuing continued iinibalcd and b'cane 
mote frequent as tunc pawed 

On May 20 19 '9 vlr devc’op-d ‘iijdcn severe pain in 
the ligbl line fossa This pam trivcllcd slowlv to th' 
epqisirniM and then I came ( en'fali ed fhe most severe 
pun was consianti) ii the ri hi line fossa \ omung b'gan 
I2 hours after lie onset of svmpoms an 1 b'cam* verv 
frequent ■-nd sohmnnoiis She svas admitted lo Mr J 
Campbells siUi leal unit in tie Soutbp 'it I’ronienad 
Hospital 20 hmus after lie onset of symptoms Oa 
admission her Ic np'raliirc piiKe and reap ration were 
normal Dehydration was obvious ami prsNlaim'd the 
siolencc of Ihc vomiiing fend mess in the rtchl iliac 
fossa ss IS extreme Ihe pilient vvm ed when th' exannn 
ing hand had d me little more tint) tovcli th' slm A tense 
oval swcihne al out 3 ly 2 m (7 5 by ' cm) was palpated 
in ihc iqhl line fossa Ising within Ihc subslarcc of the 
aldominal will pirallel with the ineuu il hgarrtnl and 
about 21 in (6 2^ cm) above it 

Strangulaicsl Spig'Iian 1 erma was diignos'd An inci 
Sion vsas made over tbc swelling and live li'tnu vsas revealed 
nficr Ihc external ohhqiic aponeurosis had I ecn incised The 
SIC contained omentum and slringiilited loops of small 
intestine vvhicli vvere kinked and bound together by touch 
adhesions sueceslini a faulv ptoh'ujcd lenancs m rather 
inadequate quarters The reck was rigid and crisped Ihc 
sac tightly It w IS big enough to admit two fingers The 
worst of the itlhcstons were divided and the intestine vvas 
relumed lo Ihc aNlomcn where normal colour was tipully 
regained The liycrs of Ihc uVulominal wall were defined 
and Ihc wound repaired Recovery was uncsentful 

CoMstrsT 

This case IS interesting as the apparent continii ition 
of symptoms following cholccvstcctonn were ascribed 
to some rcMtliial Iiscr damigc for which she had been 
treated The onset of nciite str inrul ition al first closely 
mutated nciile appendicitis The correct diignosis was 
given by the development of intestinal obstruction with 
the presence and site of the tumour 

Reid (1919) reports a case of Spigelian hermi which 
imitited an acute ippcndicitis to perfection The above 
case illustrates how deceptive this rire hernia cm be and 
the advisability of beiring it in mind when abdominal 
symptoms of an obscure nature arc found 

Wo timnk Mr Jolin Campbell for permission to publish detmh 
of tins ease 

D Watson M B , Ch B 
Bern ScoTina, MB BS 

RncitCNCE 

Reid D R K (1949) Brit J Sure as ta3 



Jan 13, 1951 


REVIEWS 


British 

Midjcju, Journal 


75 


Reviews 


BLOOD GROUPS 

Blood Groups in Man By R R Race Ph D 
M R C S and Ruth Sanger Ph D B Sc (Pp 290 
£1 lOs) Oxford BlacCuell Scientific Publications 
1950 

Ostensibly blood groups and clinical medicine have 
been living together harmoniously for some 40 years 
However the discovery some 20 years ago that there,were 
human blood groups (M N, and P) of negligible impor- 
tance in clinical medicine was a warning sign that the 
ways might part sooner or later, though the discovery 
of the Rh groups at first suggested that after all the 
subjects might develop most rapidly if they worked 
together 

Since then great efforts have been made by both 
sides to pretend that their interests are really the 
same This has led to great concessions by clinicians 
Clinical pathologists have struggled first with CDE then 
with C" D" and E“ This book should persuade them 
that the time has come to abandon the chase It is 
useless to pretend any longer that what is interesting 
and even fund imental in the fielcT of blood groups 
IS necessarily of the slightest interest in clinical 
medicine 

It may come as a shock to some clinicians to find that 
It IS possible to write a really first class book on blood 
groups without giving any definite description of a 
compatibility test This omission seems entirely 
proper in a book which is not written primarily for 
clinicians 

From now on the clinical pathologist with a special 
interest in blood groups must recognize that he cannot 
aspire to more than amateur status in the subject His 
daily work requires a knowledge of only small dis 
connected parts of it Acquaintance with the phenotype 
Le(a- b-) IS no more important to him than a know- 
ledge of the rarer poisonous fungi On the other hand 
to the geneticist each blood group system is of approxi 
mately equal interest 

This book IS written by two people who have done 
more than any others to advance this subject in the last 
few years and therefore every worker in this field should 
study It closely However, this will prove far from 
being a burden to anyone the whole work is enlivened 
by a discreet gaiety and is the easiest possible reading 
There are very few criticisms to make It is a little 
surprising to find that haemolysis by anti Rh sera— a 
phenomenon very difficult to demonstrate — is mentioned 
twice whereas a and j8 haemolysins are not mentioned 
at all The authors have been a little too respectful 
of some published work It is unavoidable that a good 
many bad papers have been published on blood groups 
and if these are to be quoted the reader should be given 
some clear indication that the conclusions are open to 
doubt 

These are verv minor reservations The book will 
save blood group workers untold hours of hunting 
through the literature Even more important, it will 
make them familiar with the methods statistical and 
otherwise which Race and Sanger have used to^deter 
mine the pattern of so many new blood group systems 

P L MOLLISON 


WATER AND SALT DEPLETION 

Water and Salt Depletion By H L Marriolt C B E 
MD FRCP (Pp 80 15s) Oxford Blackwell 

Scientific Publications 1950 

This monograph is a reprint of Dr Marriott s Croonian 
Lectures of 1946, which were first published in this 
Journal The text has been revised to bring it up to 
date He sets out, in the lucid, dogmatic fashion we 
Jiav'e come to expect of him, the mam facts of salt and 
water metabolism with the causes and effects of the 
bodys depletion of each separately and of. the two com 
bined The diagnostic and therapeutic precepts which 
follow are simple and practical and have already estab 
lished their value 

Dr Marriott has clearly made valuable use of his war 
time experience in India, and there are few points at 
which anyone will cavil No comment is made on the 
view, held by many that the urinary excretion of chloride 
after operation' and injury bears little relation to the 
plasma levels, and that the Fantus test is a fallacious 
guide to treatment in such cases His suggestion that 
salt depletion ' aggravates pyloric stenosis by super 
imposing pylorospasm is interesting and explains the 
unexpected improvement which sodium chloride will 
, often &ring about in these patients His insistence on 
the prior claim of the oral and rectal routes for adminis 
(ration of fluid is salutary in these days of uncritical 
intravenous medication 

With this httle book in their hands, the junior resi 
dents, upon whom to Dr Marriott s distress, the 
''management of salt and water depletion so often 
devolves, will be well equipped to meet these emergencies 

R Bodlev Scott 

MICROSCOPIC DIAGNOSIS OF MALARIA 

Studies from the Institute for Medical Research 
Federation of Malaya No 23 The Microscopic 
Diagnosis of Human Malaria Part I A short 
descnptive atlas of thick film diagnosis By John W 
Field llluslrated by Yap Loy Fong (Pp 1)6 

illustrated No price ) Federated Malay States 
Institute for Medical Research 1948 
In the early days of malaria research technique was 
practically restricted to making the wet blood film a 
delicate operation not to be attempted except m the 
seclusion of the hospital ward Later with increasing 
convemence and usefulness came the dried film, watery 
Romanowsky, Leishman stain and Giemsa But 
meanwhile more and more was demanded from the 
malaria research officer There came the increasing use 
of the thick film with its added difficulties in inter 
pretation,. counts were required for certain kinds of 
work diagnosis of the parasite became mcreasingly more 
important as drug treatment became more precise and 
specific, and in wartime examination of blood films had 
to be made on a very large routine scale Many 
beginning such work found there were troubles-and 
difficulties to be surmounted and advice of the detailed 
and practical nature required was not easy to get 
This helpful publication is designed to meet just such 
needs Dr I W Field has set out in the simplest and 
most direct manner, and in full detail with copious 
illustrations a description of practical requirements in 
the making and examination of blood films by (he 
malariologist After a brief account of the forms and 
appearances of the malaria parasites and points regard 
ing parasitaemia and other matters of importance m 
the examination of the blood in malaria, there is a 
chapter on the thick film and one on interpretation of 




76 13. loM 


pnvicws 


^^hll K shown in iich Tilnn Thu n fnihi triJ h> i 
ilcscnp ion of \ itioiis tcchnuiucs now ii*cd hj the 
nnhrioloi Kt in llic nniirij uni cviminnion of Wool 
liinn into inition on (he \ uuhu Uonnnowily duns 
the m it nu o' film, for lonimc lu p* i iJ u -ij »• uicl lod 
of loiinl in dfluh of Gienl'i Itininj fo. 

tlilKtcnt snupu" hhcihnr of slid- ni d oilier it fnl 
pratuil hints I lie nine of the wnil he% not onl> in 
the \tn full del 111 foin, htil in th- cMent to win h 
the luthor s osn inlmnte exp ri-n-c t Uu'-j uit-d 
Tlic rciicwtr Itiouv of no uorS ijmic co iifx h’c ird 
Ins no hcMtttiun in 'ifinf lint it will le iHcfiil wort 
of e'e eiue .nd ) nm tree no' onK to the I finiicr In t 
to ill cn, I sd in \ o t o' ih- lind s hn-lt i*i<- -uitliot 
dn..tKM., Hit) MD Cimt toniiij 

Annus i's\cf!(uof.N 

At'Ut I l"t ! Ifseli’i t It], trinWj) (f'p 3)4 

I*-'! I o I'l 1 (i i,r M -1 SI It ‘to in IV'O 
AltteJ \dl'i s n un- iMiflctt tnci't oned folh ins.o'ilj 
lu IS one of til ct -1 itu ! Jmu si d \d!cr \Siiti |i m 
re .IS o t lie 1 n fc\ c itehwoids ill It h ISC 1 .O' c pot 
of onr dsil) lunuif jinone th-ni iii'c lO its eoinp ex, 
ssiUtops'er inx vuh le pto'c t Ih ext— it to sIikS 
tl.e pntriplc o' his imlis dud p )..hoto s hxsc h-en 
iib'Orh-sl into turtcnt P'Seniin, ihoii lit is itdi,. t-d 
onl) hs the ircnu-PG ' 'th s’lntli ll e, sre rc hi oseted 
s it'i ind ssiilunii nool d mm' 

'‘find is in nlisttitiiun uid ttun- nho ssmild rcdiec 
Its III imfeit itions to tciiiis of pluici of ip cc of fescis 
ltd dipths must {I ltd SI urist cm ntiv eo ifu lot lest 
their p nho" im hc-omc ill sjmhol ind no mmd It 
IS fot this re ison tint Adlers ssoti Ins often stirxcled 
the phjsieiui ssho doutils the sslutil)' of th- I retidun 
hhicpnnt of mcntsl life the oriptnil sso ts tnsc lost 
a {00 I d. i1 in irsnslition uul «inec lhc> hise iiescr 
hecn piescnicd is more linn sober ids inecs in mediesl 
cieiiet they hise been re id niiinly b) iptnbsls 
Inf ilhbihiy Ins not been chimed fo- ihc uivhor Ccr 
tiinls Adler s principles nrc riles mt to th- prc'cnt p c 
oceupuion ssilh psychoionntic mcdieinc iind soci il 
psychntrv Mr V>iis Ins iclncscd more tlnn ii rest lie 
nient of them, ihoit{h he his done tin f.xiihfulls lie 
Ins ntlempiLd the dilhciilt l isl of fin Imi their soiirecs 
nnd rel itionships md of irieine the desekspmem of 
Adler s theories ihrouEl) the life of the nnn himself 
As i person il friend of Adler s sml no me in student 
of philosophy he is sscll qinlified to do tins IIis 
description of the unexsy colhborilion hcisscen Adler 
and I rciid in the c iris days of the psycho .in ilstic mosc 
mint, nnd boss the itiitiide of cich adminh'c in Ins 
own ss ly sv is moulded by Ins ossn person itity niihcs 
fnscimtinp re idiny In his h mils the historicxl ippronch 
to the tinclcd web of present dns theory in psycho 
pitliolotJ brinis sonic order into the siliiilion fins 
bool IS no Adler Wuhonl Tears nor is it n synopsis 
It is not all easy rciding but it is n rcisoncd uni 
scho'ariy presentation ol the iniplic iCioiis of 'induiilnit 
psycholoty in many fields inchidini that of medicine 
ind there is here little to sshich the physician could take 
exception 

This IS an important book sshich challcnEcs much 
that is accepted by many psyclii ilrists Not only svitl 
It be a saluabic companion to Adlers svork but it is an 
admirable book (or the mature physician sshosc expen 
cnee has taught him that to knosv the naturil history 
, of illness he must study not only disease but man 

ALLXANDCR KtNNCDV 



rnfMK,\r vmswioc:\ 

( till tri t t!rr lien I rl rn I Intln’n ir I's Dr 1 N 
X 1 1 Ir S-eon I c.li i<m (I'p 1) *I 7JU) Jcaa 
t.i 'IS 1 1 1 !) r I'i'O 

ihc author of this hoot on the oii'linc- of ch-a- -M 
pissiulti I frcit tl- tubject from Ihc p'l lolo-'ica! 
•i p et nlhct tlnn tic cfi-tmcal Thus ii- ri'*s oa.y 
an clement tty lee Hint of the c'lcmis'rs of ciiba*is£!rat <, 
fats an I p otems iim'er th- heuhn, dues nn lie gisct 
line del Ills imd-r mkrtn di,rs m-.ahol.sm sih- t th- 
tea 'e niiy fin I t'c ril nl II) th- •efen- of t' e r'i-> 
r'n y'linn of {'if i ic uul its coasc » nn to 1 etic mJ 
in 11 U vfc an I to dio' o! aa I catbon I'loxii'c bs yeas' 
(It lie /’ i)\i Jxtioa of falx -ml (3l at lome l-a-tS tr- 
oldrr Inosicd, e of ihe coascrxion of ammo a- ds (a 
timit e- Hid of ltsp'o,i' m to ii I'l in The de'isdro— ra 
lioa p 11 c's-x ssil'i s It uul CO fc ni n's is eenlils 
del nil'! Oil kSa-biuj s ttsprvtna fc i cal is co- 
X I'c cd Csto uoair is not n calioac 1 nn is i-c clia 
i idcf ducstii’a h It > lai- of I'lslos s sso t is thscuss-J 
Ihc Xt.oi nt of fo'il metal o'uai it I'nt o' \oi’ and 
I’cilen' o'er the c is noiliia- alo ii t' c sso » o' \t s-nc 
an' I!-n Jut na ih- simp'-r ssjys of s'ulsme oxseea 
t I'xVc and cx lot I'lOXi *c iHItp it The ssork of plisxio 
lo isti o I'l I'l tie niuiy 11 oanii d 

Ihc he t e'np cr is ihit o i Wood Tf e ai"’ior rc-ardi 
liicmop'iiiu III due to a dis'n bin-c of I'Toaihin and 
ntilhromhi’i foim tion lie often deierih-s I’.c com 
puiltsc j'lssiali y m o'he arinnh sslie'i adds some 
inie Cat Inc hit puc is dcsot-il to i sc s short i eouat 
of ill- me of luhoafiiic |< I op s The hook is dis 
ipj" nlme set mij he ol s due 'o Gctn an s ud ntt 
Out I njh'h bos'is on bioelicimstrs and passoU'cs are 
r clerabie R It A Puwai 


HOOKS' itrcrikED 

f.n r* h nU p-rvU 'r I bf rt i t here cf I i t fr-e-tfi- rr-tnel 

Prnbtrm 1 nniliei in Itriitnl tU R C i M 

ni 11 HT I"' ta' y lom'pn Cxi It I'ltO 

7de i\atioml flfiUli C/rrirr \rli is>/< nnrf ttv J A 

Son out, SI ty ni‘11, mj cict» ti’p i i9i 
tiixdon I x[t nnd Spo umoixlc IVH> 

7/c IhuelirnrirtrY fif )) liftnoitt Ilv R J SSidnies -nd 
oit-rj (Ip 7.1 '1)0 tendon Onpaixa and llxll td'O 

1 1tem tf nut nndidi-i Ry O \Sins'p» llo mex MD and 
M D S hull M D (Pp 3X7 Sli (al 1 I ondon llcnrx 
Kinipion tyso 

Meitieiit rrettimenr It) 0 IZsanx MD^TRCP (Pp td9S 
ID'S) tondin hiillcrworili list 

Pte I iinl linnelteii fe\ intlsirirninfii tli Vi Kemper (Pp lOI- 
M 5 70 or 3t 35) buiUiaii Gcotp lliicnic ID'O 

Iftlfittlrii plr den Cet nrltlnlfliel en Olfriitw) tines hf 
llic laic Piofcaxoi A Dodcitciix icviacd 1) I’lofcasor O 
Dodcilcin ttp 173 M 7 50 Or Slid) Siuiipul Georg 
lliicnic 19S0 

Prnlnltnn dee Witlitigsitn Infeltionibraikleilen Rf Ihi 
Inic I’lofcssor C Ilc|lcr reused bv I rofessor II E Unte 
(Pp 377 M 14 70 01 S3 50 ) Stimpnrl Ucofi IliiCnic 1930 

Ampntterte nnd PrflOtesen D) Dr R Cilc (Pp 3S 
M 3 to ) Jcntl GusIih' I isclicr 1950 

Cl ttnd/a^en dee ndl ohi^ie Ry Professor 11 Martiiu 
(Pp 144 M 33 40 or $S 55) SlUUgxrt Gcorp Tliicmc I9S0 

Atlas der Nonualen J1istotcn;ie nnd Mil eosAapiselien A natninif 
des Mettselten Ry Piofcssor E Von ilcrraUi nnd Professor S 
Abramme (Pp )39 M 4S ) Snillgart Georg TJiicmi I9S0 



Jan 13 1951 


MEDICINE IN AUSTRALIA 


Brittsii 

MEDtCAL Journal 


77 


BRITISH MEDICAL JOURNAL 

LONDON 

SATURDAY JANUARY 13 1951 


MEDICINE IN AUSTRALU 
On January 1 1901 the Commonwealth of Australia 
was inaugurated by the union of the six Colonies 
which had each had a separate Government up to 
tkat time It is fitting therefore that our contem 
porary the Medical Journal of Australia should for 
Its first issue of 1951 publish a jubilee number which 
reviews the status of medicine in Australia at the 
beginning of the century and its progress and develop 
ment m the last 50 years The 14 papers m this 
special issue are not only eminently readable but 
together they make a useful contnbution to Austra 
han domestic history 

During the nineteenth century the medical practi- 
titioners of Australia had come from abroad having 
been trained m England Scotland Ireland and more 
rarely on the Continent of Europe but towards the 
end of the century medical schools had been estab 
lished in Sydney Adelaide and Melbourne from 
which already a limited number of practitioners quali 
Tied each year In the towns the family practitioner 
held a position of trust similar to that of the family 
solicitor and banker and his advice was asked about 
many matters of importance to the family apart from 
illness Consultants in the capitals of the States 
visited patients with the family practitioner and also 
saw them at their consultmg rooms In the country 
conditions were different largely because modem 
transport had not broken down the isolation of rural 
communities it was not unusual for a doctor to ride 
on horseback to visit a patient some 20 miles from 
his home or to drive in a horse buggy Motor cars 
came in during the first decade of the new century 
but the country roads were as a rule bad and it was 
often impossible most of the year to approach the 
farms m a car 

At the present time half the population of Australia 
IS concentrated in the State capital cities and most 
of the remainder five m the more fertile coastal areas 
of Southern Queensland along the borders of New 
South Wales and Victoria and on the south coasts 
of South and Western Australia Conditions m the 
big cities are much the same as in other well 
populated countries the treatment of illness being 
undertaken by the family practitioner with the assis- 
tance of a hospital easily available The centres of 
medical work and teaching are the hospitals These 
were built in the early days mainly for the desUtute 


sick the visiting doctors giving their services free In 
the country towns hospitals were often built as in 
this country as memorials to some person m the dis 
trict During the past 50 years hospitals in Australia 
have grown in importance and their' function has 
been enlarged to include not only treatment of the 
sick poor but other senously ill patients Small 
private hospitals in the suburbs and country towns 
were established especially for maternity and minor 
surgical cases but gradually these have had to give 
up through being unable to meet increasing costs 
New hospitals m the big centres have been built on 
modem lines (there are some impressive photographs 
of these in the Commonwealth Jubilee Number of 
the Medical Journal of Australia) and accommoda 
tion has been provided for the practice of many 
specialties All this of course means that more nurses 
and auxdiary staff are required The cost of build 
mg too has increased for it used to be possible to 
build a hospital for £200 or £300 per bed but now it 
may be ten times as much The expense of providing 
accommodation for nurses and other staff is equally 
heavy, and the Government has therefore had to step 
m and help to build equip and maintain hospitals 
Naturally with the growth of population there has 
been an increasing demand for doctors and for a 
standard of medical care equal to the best obtainable 
in other parts of the world This has been hastened 
by the impact of two world wars on Australia 
Gradually medicine became a more attractive pro 
fession and many more doctors were trained locally 
Some of the best of these came to Great Britain and 
settled m various posts others having been over 
during the first world war and having taken a higher 
qualification returned to raise the standard of prac- 
tice in their own home towns No great local dis 
covenes were made in these early days but no time 
was lost in applying in Australia the results of world 
wide advances in medicme and surgery It was 
dunng the second world war that rapid progress was 
made by Australian research workers especially m 
solving the many problems ansmg m tropical war- 
fare New knowledge of malana and dysentery 
proved of the greatest value to the medical services 
of the British and Umted States Forces The impor 
lance of medical research in Australia has just been 
fittingly recognized by the award announced m the 
recent Birthday Honours of a knighthood to Professor 
F M Burnet, of Melbourne The standard maintained 
m the medical schools of Australia has always been 
high Nearly all the early professors who went to 
teach the basic sciences were Fellows of the Royal 
Society vvith international reputations The stimulus 
these men gave to then students was carried on into 
then- hospital trammg where the teachers were fir- 

/■ 




Jan 13 1951 


COLONIAL MEDICAL SERVICE 


BRVron 

Medical Journal 


79 


due pnmanly to unsatisfactory rates of pay but an 
equally powerful reason for lack of recruits may be 
a lingering suspicion that out of date methods of 
medical administration are still to be found in some 
places Professor G Macdonald’ has pointed out 
how shortage of doctors m some Colonies leads to a 
heavy emphasis on routine work a consequent lessen 
mg of interest m research which m its turn again 
impairs recruitment Much was hoped of the en 
courageraent to medical research which would come 
from the establishment m 1949 of the Colonial Re 
search Service but so far these hopes have not had 
much to justify them 

About three months ago the House of Lords de- 
bated the subject of medical man power ‘ and several 
speakers took the view that the best way of overcom- 
ing the shortage of doctors in the Forces and Colonial 
Service was to enable men and women to transfer 
freely without loss of pension and other rights from 
one service including of course the N H S to another 
The natural corollary was as Lord Haden Guest 
pointed out that the payment received by medical 
officers in the three Services and m the Colomal Medi 
cal Service should be equal to that received in the 
National Health Service The Government spokes 
man in this debate Lord Shepherd was obviously 
impressed by the arguments put forward and told 
the House that he hoped something good would come 
from the deliberations of the interdepartmental com 
niittee which was considermg the co ordination of 
medical services The thm end of what is hoped will 
eventually be a large wedge has already enabled 
doctors in the N H S to transfer for a limited penod 
to the Colonial Medical Service without loss of super 
annuation rights’ (and with the grant of a gratuity 
at the completion of their service) and m West 
Afnca young doctors accepting certain Colomal 
Office posts are thereby able to discharge their 
liability to military serMce 

For many months past the Colonies and Depen 
dencies Committee of the B M A has been negoUa 
ting with the Colomal Office “to achieve a broad 
equality of reward not the same figures m 
pounds shillings and pence but the same real return 
for services rendered in each temtory a return which 
IS comparable with the remuneration of doctors m 
the National Health Service”* From time to time 
agreement has been reached on revised scales of pay 
in certain Colonies * and though much remams to 
be done it is clear that the Colonial Office fs as 
anxious as the BMA that Colonial Governments 
will take sensible steps to attract good medical men 
to their service In East and Central Africa for 
instance the salary of a medical officer in the ordinary 
arade used to nse from £865 to £1 320 Under a new 


agreement it now rises to £1 590 This may be 
compared with the salary of £850 rising to £1 150 
awarded by the Industrial Court to assistant medical 
officers m the public health service in this country 
Further the income tax payable by a single man at 
the beginning of the assistant medical officer scale 
in this country is about £200 In East Africa it is 
about £75 

In the past complaints have been made that 
the information given to applicants for posts in the 
Colomes has been inadequate or even on occa- 
sion misleading The Colonial Office has recently 
taken steps to remove this cause of dissatisfaction 
There are of course stdl many anomalies and unsatis 
factory features about conditions of service for 
doctors in the Colonies The thorny problem of pn- 
vate practice by colonial medical officers remains un 
solved The position of the clinical special st vw a vis 
the administrator may not always be happy — bad 
“ man management ” is still sometimes responsible for 
much bitterness In general specialists arc recruited 
from men already m the“service but a concession has 
recently been made to men with higher qualifications 
who may be thinking of joining the Colonial Medical 
Service for in some Colonies they may begin their ser 
vice higher up the salary scale than less well qualified 
entrants Though no guarantee can be gived that a 
young medical officer will be employed m his specialty 
the Colonial Office states that directors of medical ser- 
vices would see that such a man was given as much 
work m his own subject as possible 

The attraction of medical work in the Colonies has 
always of course appealed only to relatively few of 
those who qualify and this was so even in the days 
when reraunerauon was much better than that obtain 
able by doctors in civd practice in this country To 
some life in a particular Colony may have attractions 
which more than counteract poor conditions of ser- 
vice and to others no financial inducement could pos 
sibly overcome their dislike of living abroad Any 
one who joins a service knows fairly well the sort of 
disadvantages which are inescapable m even the 
most bemgn of hierarchies It is unlikely that any 
single disadvantage — separation from home and often 
from families the inadequacy of salaries m some 
Colonies the expense of educating children at home 
early reUrement — would deter doctors who might be 
attracted to the work but the total effect of these 
doubts IS discouraging However there are signs 
that Colomal Governments which wish to build up 
medical services comparable to those in this country 
realize that they must provide for their medical officers 
condiuons of service at least the equal of those obtain 
able m Bniain and some practical steps have already 
been taken to this end / 




Jan n, 1951 


Oi^CRATING THEATRE TECHNICIANS 


Bwntn 

Midical Jolrnal 


81 


standpoint he will ha\e as part of his team a member 
who out stays the ever chanting theatre staffs and a 
craftsman who by learning each surgeon s fads and 
habits eliminates minor frictions and produces the right 
tool in good condition a\ the right time thus leading to 
the development of a partnership of trust and efficiency 
essential to the quiet work of good surgery In order 
to attract the right type of man the high standard of 
training set by the association itself must be maintained 
and recognized, and the association is now engaged in 
negotiation with the Whitlev Council on this issue Its 
work deserves the full support of the medical profession, 
for if operating theatre technicians are graded in the 
same category as theatre porters or orderlies the whole 
aim and object of the association will be lost 


QUINCEhiTENARY AT GLASGOW 
Just 500 years ago in Januarv, 1451 William Turnbull, 
Bishop of Glasgow, founded a university the fourth to 
be established in the British Isles On that date Pope 
Nichohj V issued the bull granting permission for its 
formation and for its students to be licensed to teach 
anywhere in the civilized Christian world but for many 
years after the foundation was extremely poor, and 
indeed Turnbulls original purpose was probably little 
more than to tram clergy for his own diocese It was 
only the faculty of arts that flourished and its college 
began building in 1453 m the High Street near the 
Cathedral at a time when Glasgows total population 
was no more than 3 000 or so 
from such small beginnings through years of 
obscurity the ecclesiastical crisis of the Reformation, 
and the struggles between Presbyterianism and Epis 
copacy in the seventeenth century the university 
struggled on and grew and began to (lower in the Age 
of Enlightenment the eighteenth century, despite the 
nepotism and small personal feuds that were then so 
rife Glasgow was growing too as a result of trade 
with the American colonies from 14 000 in 1712 to 
83 000 in 1801 and the foundation of the Royal 
Infirmary in 1794 provided a hospital on which to base 
the medical school A professor of medicine had been 
elected as early as 1637 but the chair lapsed in 1646 
and was re established in 1713 to be followed in 1720 
by a chair of anatomy with botany The duties of the 
professors were to give lectures if five students pre 
sented themselves and to examine candidates trained 
elsewhere for the MD degree 

U vvas the vigour and enthusiasm of the famous 
Cullen which set the medical school on ns feet After 
lecturing in his own private school he vvas brought into 
the university in 1746 and from this time and that of 
his pupil and successor Joseph Black who discovered 
carbon dioxide and made Glasgow an important chemi 
cal centre there was nearly alvvavs an annual enrolment 
of 100-200 medical students among them such men as 
William Hunter and Smellie ihd obstetrician The nine 
teenth centurv saw a further vast expansion and con- 
solidation under such men as Thomas Graham the 
physipl chemist who first studied osmosis and colloids. 


and Joseph Lister who carried out his famous cxperi 
ments on antisepsis while he vvas professor of surgery — 
at the suggestion of the then p ofessor of chemistry, who 
1 new of Pasteurs work To day on its 500ih birthday 
the university which has done so much to shape 
Scottish life IS one of the leading academic centres of 
Britain, and educates 7,000 students annuallv to play 
their part in schol irship and leaching in government 
and law and medicine May it in due course celebrate 
a successful millennium 


COMMITTEE TO STUDT GENERAL PRACITCE 
The Central Health Services Council has appointed a 
committee to study general practice under the National 
Health Service Its terms of reference are to consider 
and make a report on whether the existing-arrangemcnts 
for engaging in general practice under the National 
Health Service are such as to enable general medical 
practitioners to provide the best possible standard of 
service and in particular, to advise upon (1) the range 
of work and standards of practice which should be 
expected from the general 'practitioner by the public 
and medical profession (2) types of general practice 
(3) mode of entry into general practice (4) non medical 
help, (5) equipment and environment (6) method of 
remuneration (7) liaison with hospital and specialist 
services , (S) liaison with local luthority services 
The members are Professor Sir Henry Cohen (Liver 
pool) chairman , Dr G O Barber (Dunmow) Dr S C 
Barnes (Wirral) Mr N F Baylis (Clerk Nottingham 
County and City Executive Council) Dr W Russell 
Brain, P R C P , Dp J A Brown (Birmingham) Dr 
B Cardew (Genera! Secretary Medical Practitioners 
Union) Dr H Guy Dam (Birmingham), Sir Allen 
Daley (Mcdieal Officer of Health and School Medical 
Officer LCC) Dr E A Gregg (Chairman of Council 
of B M A ) Dr W V Howells (Swansea) Dr Emd 
Hughes (Ruthin) Alderman Mrs V F King (chair 
man Southampton Executive Council) Professor Hilda 
Lloyd P R C O G Dr W N Pickles (Aysgarth) , 
Dr A Talbot Rogers (Bromley, Kent) Mr E \V 
Scorer (member of Sheffield Regional Hospital Board) 
Dr Stephen Taylor (London) Dr J S Thomas (Manor 
Park, London), Mr H P Travis (Secretary, Bolton 
Hospital Management Committee) Sir Cecil Waleley 
P R C S Dr C W Walker (Cambridge) The secre 
larv IS Mr H N Roffey of the Ministry of Health 
Any person or body wishing to submit evidence to 
the committee should first give notice to the secretary. 
Room 358 Ministry of Health Caxton House, Tothill 
Street London S W I 


We record with regret the death on January 3 of Sir 
Arthur Hall in Sheffield at the age of 84 He was 
emeritus professor of medicine in the University of 
Sheffield with the foundation of which in 1905 he was 
closely concerned 



N’ n I'^M 


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lo[ I of anil bioiKtiili' llioiiili Ilie rvu I In \ h vh 
cithi.r IS cm ll CTiinol be I'elcrinin il lUoii-bilis n 
r iri m ilrs itfiiosp'icics \slirtli'-| Ilie cliniitc b- 111.11.. 
or Iropicil II IS ilso less to iiio.'n in oiif siimnirr linn 
in oiir ss inter lliil ihe tonnccion 1111) liol b- so ilircvl 
IS It setnis for on foi i > il mip mil coM ih\s peop’r 
tend to son( rt( ilc in umlciscnld ilril iiriotimlims iiul 
tills IS fisoiiribk to the sprciil of infetlion lliis mi\ 
ivtll be more import ml linn m\ pioprrlv of lltetlmnle 
ilstif Morcostr Ihcrc iii Ik t ililfeicntc of b iticiio 
lopicil cnMronmcnl in diffeienl tliniilic toiiiliiions - 
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from till Ihroils of rliciiinilit sub)ccls isticn llte> |o lo 
siibiropicd dim lies uul lo rt ippi ir on rcliirn to i 
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climilic fitlor 111 ly in ficl be Iu|cly i Intlcnolo, K il 
one 

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logy Ins been cslibhshcd — A/itrocon in < (irnrr/m/n 
sliphylococci pneumococci iiid sirtplocotci immii 
others m ly ill ht found Infeclion seems lo pi ly nn 
overwhelming pirt in infmls Ihe hiby often h ivinp 
very hllle resist incc lo orginisnis 10 ivliich in I ilcr life 
he will become more adiplcd In the ndiill il is 
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from the ttiehci nfir t'utifo'omy b i iii 11 m\ e n ' 
no pilho ctik orpiimnii itc found 1 id Ihe c lusc 11 is 
then ssrll be a situs 

ll is ills iss dilluiill to tiss-ss ill- pio nosis in 1 n t' 
thcicforr sifcr to uhmt most eas s to hospilil A If" 
tiscs ssdl rrnuirc Inetico'oms uul in Ihrse delis i' 
dint crons tlie decisio 1 to op-rtle suit 1 bned on the 
iiniouiil of reee sion of the soft pirK of llic ehest diiiine 
inspir.dioti the pulse iiml Ihe tenet d eondilion~i ehd.l 
sslio ‘trill I'Ics md puls up i In hi tins t el ihri'Uth on 
Its ossn hill the pile hsllcss eroiips ehdd iisinlts 
requires Irieluolumy 

Most of tlie niodirdc e ises pel sscll on Ihcir o'sn 
nnd this iinkcs 11 ddlicult to assess Ihe s due of ms 
remedy Our routine is to iise a mivtiirc conliiiiini, 
5 mi of pethidine thue nines i d is nnd d50(HK) iimis 
of pemedhn csers six hours On Ibis rcj mie sen te" 



Jan 13 1951 


ACUTE BRONCHITIS 


Bmtoi 

Medical Joctcsal 


S3 


cases require tracheotom} but whether reco\cry is due 
to the treatment or not it is difficult to sa> We ha\e 
also used chloramphenicol in quite a few cases, and in 
some dramatic improvement has been apparent In 
hospitals where croup is a common cause of admission 
there will probably be more scepticism about the value 
of the drug than in hospitals where only the occasional 
urgent case is admitted At the moment it is probably 
idvisable to try the drug m all serious cases With 
regard to steam treatment the tendency is to use this 
less and less but in the well chosen dry case its 
effect can be very satisfactory 

Acute Bronchitis 

This IS not always an easy disease to diagnose in very 
voung infants apart from the fact that the baby is 
obviously ill, there may be very little to go on The 
temperature is often raised to 102-103 F (38 9- 
39 4 C ) and respiration may be noticeably increased 
On the other hand, symptoms may be referred to other 
systems diarrhoea and vomiting are quite often the 
presenting features or restlessness and irritability may 
be so pronounced as to suggest the possibility of menin 
gitis Exgmination of the chest may be of little help 
a few moist sounds may be heard but noises arc 
frequently referred from the nasopharynx In fact 
diagnosis will often be conjectural and will depend 
largely on excluding other causes of pyrexia In the 
older infant as the time of teething is approached the 
disease tends to be less acute and the symptoms more 
tvpicdl of bronchial infection 
The severe case is a medical emergency and in most 
instances is probably better in hospital The social 
background in many cases is important but the prime 
cause in nearly all is infection and it is therefore 
rational to use anti infective agents Penicillin is often 
effectise and can be gisen orally to infants under 3 
months old 50 000 to 100 000 uruts dissohed in a few 
millilitres of normal saline can be added to each feed 
or in the case of a breast fed infant can be gisen by 
spoon after the feed either in saline or added to a little 
expressed breast milk this dosage may be excessive 
but It guarantees therapeutic concentrations To older 
infants because of the destructive action of gastric 
icidity on the drug penicillin should be given bv 
repeated intramuscular injection if done si ilfullv this 
IS not so upsetting as might be supposed Sulphon 
amides in the form of a sweetened suspension arc often 
of value One tablet (0 5 g ) of sulphatriad — a combi 
nation of sulphadiazinc sulphamcrazine and sulpha 
thiazole in one tablet — can be given four hourly to 
a voung infant for the first 24 hours and thereafter 
0 25 g four hourly for the next three or four davs it 
IS not often necessary to give the drug for a longer 
time Cough mixtures of anv kind arc undesirable in 
infanev is thev mav upset digestion without affecting 
the bronchitis 

So far as is possible the feeding of the child should 
not be interfered with and if a breast fed baby is 
admitted to hospital the mother ought to be admitted 
too breast feeding bv a mother visiting the hospital 
for each feed is rarelv successful unless the home is 
verv near the hospital If the mother cannot be admitted 
the infant should if possible be treated at home The 
child must be kept warm and must not be disturbed 
unneccssarilv and bathing except to remove soiling 
ehould be forbidden Manv of the more Severe cases 
will require oxvgcn ard the onlv satisfactorv ways of 


giving It to babies are in an oxygen tent or better still 
m a perspex oxvgcn box 

The above treatment is that required for a severe 
case, and a large proportion of the younger cases arc 
severe For less acute cases careful nursing, feeding 
and warmth will be sufficient 

Acute BronctiiolilLs 

In infants this is usually a fulminating condition 
death occurring within a few hours The diagnosis 
IS often made only at necropsy when the sole macro 
scopic finding is that thin mucopus can be expressed 
from some of the finer bronchioles on section some 
bronchioles will be seen to be packed with pus cells 
and the surrounding alveolar spaces may contain fibrin 
with or without some pus cells Pathologically the 
condition is therefore not readily distinguishable from 
early bronchopneumonia except that death h is prevented 
the full development of the pathological picture We 
have seen the condition develop m infants already in 
hospital for other conditions but most cases arrive m 
extremts and death occurs shortly after admission 
Abnormal physical signs are not usually present and 
the condition can be suspected only in an infant who 
within a matter of hours becomes desperately ill 
possibly with evidence of acute respiratory distress 
Emergency treatment vvith oxygen and warmth is 
obviously required and if the child can be brought 
through the first few hours treatment as outlined for 
acute bronchitis must then be energetically pursued 

I 

Clinical Mamfestations in Older Children 

In toddlers and school children there is a marked 
change in the aetiology and clinical manifestations of 
acute bronchitis The disease loses much of its immcdi 
ate severity and death due to uncomplicated bronchitis 
IS rare Acute laryngo trachco bronchitis still occurs, 
but It IS less common and in the older child the condi 
tion IS less severe There are no cases of acute bronchio 
htis corresponding to the fulminating type seen in 
infancy when the inflammatory condition extends, the 
clinical manifestations tend to be rather those of defi 
nite bronchopneumonia On the other hand bronchitis 
causes much of the minor illness of childhood and is 
responsible for much debility and poor health In a 
proportion of cases bronchitis may represent the early 
stages of later chronic conditions such as bronchiectasis 

While acute bronchitis quite often occurs in perfcctlv 
healthy children frequently it arises apparently by 
cxt"nston from chronic sources of infection in the 
upp^r respiratory tract The problem of what are 
and what are not unhealthy tonsils and adenoids is 
a question one has no desire to discuss but most 
practitioners have seen at least some children in whom 
a succession of colds and attacks of bronchitis have 
stopjied onlv after the removal of the tonsils and 
adenoids Whether in the successful cases the tonsils 
and adenoids have themselves been acting as sources of 
infection or whether mouth breathing has been more 
responsible for the bronchitis one cannot sav Chronic 
nasal catarrh often associated with enlarged adenoids 
also seems to be causally related to repeated attacks of 
bronchitis as docs chronic infection of the sinuses 
What the precipitating factors are and whether climatic 
conditions are as important as thev appear are matters 
for conjecture The bactenologv is always difficult to 
establish but in some casts at least there is evidence / 



M J\N 1'>M 


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til \t *MK ilormti ml p itlii' rti h lut t '—d fc j m *'* 
in the p^^t (t'r m uul'* up, tc pi it ' s or iS 

tcntc Miuiviti ipp'-\u I jtn o i! i, itn ii» t- 
tc^poHMl'lc for Miv c\ )i 'p iltai\ of vu*r h »m hi i 
Moiosc tn i vh v ^ thr t " i*f i o t> ''' h 

the i>t^ int'in is r Oiv- rmv m in 1 I 

ihcs/* ittuis I ul Ihi IS s one o^ - ip hi l» t n 
b-* M)ssss'‘l \ O lU til 0 ihvi hnl i. » r 

Ac’ile brop<hili\ iv v u is i to nji a»i * of ft i * 
inUttioiis ih I r »’t ^'In h n i ^ s t ssr t , i-* 

^.o\ h \ c the t t'nm ' Kit In -iM 1 !* ! ?' * * 1 1 

luon hill n 1 ' 1 I f t I*- :* »i* \* >s p * o ti 

sh i\ rail It ti i 1 vtt ip ! 1 

1 1 liiti »' 11 ' !i ' <1* ^ <• I > ’ 1 

i'l 'r c'lit ! c I (*<> n ' i’ • t i t! > i* 

''I m i'iilt> 

llr^lnt^tlI^ In \ilii!*» 

I 1 C f I’ 11 ' 1 ' 1 ' I 1 t! r 1 > (1 ( 1* >' V » ' 

II to i'll 111 I (i h It 11 II' In' ? I'l ‘ 

l pp c pit Si* I 1 I ii' I ’-t^ I lit t'l ( n Jt Pi'i 

; 11 1 ir tin '1 i' I'l I i! It i I " I A I 1 tt* ti 

p It || t lUiI ! I t'l it 1 1 t’ i' i'' li I 1 ’ 1 

l I I ll U c til' 'licl 1 I'-tjll ^ 1 

•I i! t m 1 11 i' I'll ill 1 \i'i ' III' t ' 1 . 1 1 1 

llll ti I I I'ltl 'ci' 1 1’ ' t ' 111 Ip t' I " 'ill* 

('i iidin ft I 'iTiit I'tc 'i > 1 it'i ti I ' 

I* I'litli li 1 I '(• ifift I ti _ ' tl 1 1 ' 1 

Ino tliilii n 1 1 mil I' , I't tl I it i* 

I 1(1* -Ill'll Clt'P’ II ill- 11 t' O- 1 1 1 i' 1 ft 1 I 

t Mill t ill fji- I’rp I'r 1 i" 1 * 1 It 11 I ! I t’ 

I 10 it'iilii Hill p' il’’ 1“ I i* I I' t'l 11 It r» * 
fiom Ihci- p* i!' iilic I'm i* i'> i'll- 11 I ' ' It 
Ire It ihc l 1 u'llio 1 r nil ill trl , II 1 111 1 t' p fin o' 
p t-iinionn 

I Ilf on cl I mil llll iti c iiil'i i( 111 o' i*ii"ii 
mil 111 lime oflcii (mill licutu'ir iil mu tltoi' i i 
p t cut mil Uurc mil luii I' cii to i/i fo if ii «' 
liio I’ llll hclimil lie Ic null utiimi mici! I t tl > 
liitlini mil ii'l-n ptinlnl tmtli u t imm > i p tui i 
il lliii Mi(c I till llll llll 1 S iitirliio- I mil llll 
mill liolicnci 01 . 1 . 111 ' Ilic icMMsi'lo'c n mmll' 

r ii'cil lo ‘I'l IIKl J (17: 17 s f ) Ilrpili-ii im' 
be 1 link IlmlKil mill bruin " nct\ ejei Inn Itirre u 
no fc il ilisirc" Till! Ill nu pnieiH' isir nl in nmu ibnn 
n lliis sloe III llll. bilicf tint llic) "ill 'nlc oil llr 
nt itt tin. mini rcmll n i 'ctiic iHne" \llet llic 
fif'l tl i\ in nio'i t itc' the tpiilnm b-'.oin- ittoic ( lo 
fust mil llll. toiijli ci'iei Ikn!tt.lu mil inilooib 
ippcir mil ifttr ["o or ilirti. ili" in bcil llic pnitiii 
bt.j ins lo ficl uiiilc "til illlioiiili tlill iioiiblfil "ilh 
i tout li Most pniiiils lie lip mil ibniil ni iin "nliin 
stten to ten di>s 

Ls mnniilion of llit tli si "ill itveil nolhiiu bitoiul 
some Inrslmtss of llit bic nil Mnimls mil probibl> 
clifTiist moist rilts I litre nrt no art is of tfiillness 
in I sotil frtmniis is nol ilfttlnl 


1 nil' 

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lll C'l , ' t p ' -1 t 'l- ' - 1" 1 i ' 

i ' , » " f t p' 1 1' I > 1* ' r -> - o J I ' 

rt - 1 ' ' A i' i' ' e I* 1 * is' 

t> S > , ' 1* IS - J ' A I t f 

f ! ' ill I i * t I - * il t tv'-> o' ' * 1 * f 

I If I 11* It ' s I* ' f 1 K ' I ' 1- ' I ' A 

(,i I I’l' 

InC 1111-1 111 n I'l Slixi'iO S|fi-*riOiis 
In « (' S I Itil'i 1 lit - I t n 11 ' |1 I S > 

n nil I [ i fl I c I fl i M- o " I ' rfi I ' e*' * * '* •* 

tli> ili'Iici 1 1 ti’i *i A I 1 I Ic ' II llA ' I Ip 

fip'i n o' I'l n ihn c'l i-l o in i ' 1' pi' 

triieli '1 If' 1 ' I i' I "-re bil ii tl i * i s'll el* i- i il 
iicA It I f i! »ul 'fill i ' Sit *i r I ' c*'i*s*i'e b tl i * *'* 
lion I'f 'trim m t! aIc * ' I'li h i i ii 'I O'- lien ' * 
" If nil Ic iK 10 'll It n nil aI'i n ir I p of il 'i p i ' * 

sr fclio ' inoic cilctti'ili ih in ois e\ps*i iaiiI In 
tlnlili n ilie ' ip nir t ni I e nlmn "'cicvl i *' I ' o' e f * ’ 
if sleimlrlllc iM r tliiMtc i ai il nliitl' tin in' i* ff * 

III orllio lot mini r I't ftoni i tnijo \M n lb ' 
inelhoi's ue in t 'iitsetifnl tis! ini c ihcf o i I'M 1 i 
s'fnp of tv iliM r sbonlil 1 r vi'cn 


fltncnil rrtalimin 

In most cists llic illntss "ill tscnlnill' tit it up 
without m> spcciil Ircilintnl but onl) n llit tosi of 
sever il "tcls iimbnl ml illness tlnrini "liitli limt llit 
piticnts irc i miisincL mil tl in( cr lo llieniscltts iiul 
to other pcopk I here is no sneb lliini is shilim 
off in lit ick md llitre can bt no doubt 111 n llit inosi 
csscntnl thing in Ire ilment is lo tonrinc llit pilitnl lo 
his house ind if possible lo keep him in bed for i tl is 
' or two I Ins mc-isiirc nlone will ihoil in \n> of the 

I 


MtKti\ In ihr llmnchl 

Ihc uve I'f in c\[ dor ml ot vomh in»\l\ir». lo ii lU v 
ihc \ i.iclion I'f llic hrons.!inl \cr\ r u h h\llo''^vl 

!\ tr uliiion iinl t wiik I'r cM.n uiUI \\j\ W of tlrn>> In^ 
been UNCv! Ilic c ilrufs \rc mi lo »i.t in oik of liiuc vvW' 

I lu t. in ihc lirsi y ''In tintiniN for c\nnp!>, 

ipLi.n.uinhi oiunonintn c irt iumu In hrjt i*om. i!k' 
tfiuis <. uoc \onniini »n\I with ihc vonniun iluu i> i fi n 
topions txpcvior ihon ihc brondn il imi jhmis I ci k 
rtlliNh slimnliUvl lhrou|,li ihc \ ifU'' centre rheir is 
t\pttU»i mis IS I ivcil i'll llic issu nplh'n lini ul cnulKil 'v 



Jan 13, 1951 


ACUTE BRONCHITIS 


Bumui 

'UDICjO. JOLTlSfcL 


S5 


Kill still excite secretion in the hronchul mucous glands 
The second type of expectorant is exemplified b> potassium 
iodide This drug is excreted partnlK by the bronchial 
mucous glands and in passing through them stimulates secre 
tion This certainly occurs in patients hypersensitive to 
iodide but whether there is anv such action in normal indi 
viduals is doubtful Drugs in the third croup of expec 
torants of which tolu and benzoin are examples are excreted 
by the bronchial mucous membrane when by irritation they 
ire said to excite secretion drugs in this group also act as 
t istric irritants 

There is a tendency to divide expestorants into two groups 
— stimulant and sedative expectorants — although the only 
possible pharmacological effect of in expectorant is to pro 
mote secretion At least three different interpretations of 
the term stimulant expectorant can be found in the 
literature most commonly it means that the expectorant is 
one which induces a copious flow of secretion in the early 
dry stage of inflammation it may also be applied to 
expectorants sucb as squill and ammonium carbonate which 
have a sccondaty stimulating effect on the heart and thirdly 
It is used to indicate that certain expectorants apparently 
stimulate repair of the bronchi il mucous membrme The 
term sedative is usually applied to a cough mixture rather 
than to a single expectorant drug and indicates that the 
mixture contains both vn expectorant to promote flow of 
secretion and a drug such is codeine or heroin to allay the 
patients cough — a combination which docs not sound com 
pletely logical When the word sedative is applied to the 
expectorant drug itself it has no clear meanyrig unless it be 
thit the drug in being excreted through the bronchial 
mucous membrane at once stimulates the glands into activity 
and soothes the mucous membrane bv some other property 
but IS there any evidence of such activity ’’ 

Often both stimulating and sedative expectorants arc com 
bined in the same mixture reminding one perhaps not 
unjustly of the tragi comical classification of Polonius Is 
there anv real justification for the use of cxpectormts ’’ 
Is it really justifiable to flood the system with gastric irritants 
in order to treat a cough'’ It will be argued that couch 
mixtures ire often effective this is true but is their action 
due to anything more than the sedative effect of chlorodync 
codeine or heroin t 

Secretion from the bronchial glands can be stimulated 
effectively by simpler means Copious hot fluids bv mouth 
will almost certainly be effective with or without the addi 
tion of alkalis the fluid and the heat arc probably the 
essential constituents in the many recipes for gruel and also 
the varieties of alcoholic hot drinks Inhalation of steam 
will also aid secretion often very rapidly It is doubtful 
if anv combination of expectorant drugs can produce an 
effect comparable with that obtained by these two simp'c 
measures 

In many cases the mucous glands secrete abundantly and 
the problem is to reduce secretion The parasympathetic 
system controls secretion from the glands so that atropine 
md belladonna bv antaconizinc the parasympathetic will 
tend to reduce secretion 

In an attempt to alias cough then wc have s*en 
that atropine or belladonna will allay spasm and drv 
up secretions if excessive a painful drv hacking cough 
can he soothed bv steam inhalations and these along 
with copious hot drinks will also help to promote 
secretion if this is thought necessary In mans cases 
cough can be relieved along these lines but when it 
is specially persistent or distressing codeine should be 
given Svrupus codcinac phosphatis BPC contains 
' cr (16 mg 1 of codeine phosphate in I dr (4 ml) 
and to an adult 2 dr (S ml ) three times a dav for 
several davs is not excessive — the BP do c of codeine 
IS ’ to I gr (II to 65 mgl Small doses arc not effec 
tive rhere is the thcorc teal objeetion that cough 
should not be repress-d when there are secretions to 


be coughed up but in a disease such as acute bronchitis 
there is no danger except in very debilitated patients 
and voting children Linclus codcinac BPC contains 
^ gr (8 mg) of codeine phosphate in I dr (4 ml) It 
IS really the syrup of codeine diluted with the syrups 
of wild cherry and tolu and there is no advantage in 
Us use The pill already mentioned containing codeine 
phosphate i gr (32 mg ) and extract of belladonna 
} gr (16 mg) brings great relief 

Chemotherapy 

It has been pointed out that a variety of organisms 
may be isolated from cases of acute bronchitis — pneumo 
COCCI streptococci Mtcrococtu^ calarrhaltv and so on 
— and It cannot be claimed that any arc responsible 
for the condition Moreover in a disease m which 
acute symptoms tend to subside so quickly there is 
little chance of bacteriological investigation so that 
any treatment aimed at a causal organism must be a 
chance affair Nevertheless the use of sulphonamides 
or penicillin often seems to prbduCL good results 
although It must be emphasized that improvement may 
be due to the general treatment of the patient In 
children of school age who suffer from recurrent attacks 
sulphonamides do sometimes abort the attack if given 
at the onset their repeated use requires caution 

Penicillin is best given by inhalation if possible an 
electric atomizer is the ideal method but there arc avail 
able several small plastic inhalers which are satisfactory 
these are usually charged with 100 000 units of pcnicil 
lin as powder in some and as liquid in others and this 
treatment is earned out every three or four hours one 
charge being enough for three or four treatments If 
injections arc given then the best preparation is a mix 
lure of plain jjcnicillin and procaine penicillin and injee 
tions need be given onlv once every 12 hours There is 
no indication for anv of the newer antibiotics and it 
must be emphasized that the use of any anti infective 
agent is entirely empirical In most cases confinement 
to bed and simple methods of treatment will prove 
effective 


MEDICAL FIELD UNITS, NIGERIA 
THEIR FUNCTIONS AND WORK 

nv 

J C CHARTRES, BM, B Ch 

Mctlical Officer Cnlnnial Mefficnl SerMci 

This article may not contribute any new knowledge to 
medicine but it is intended to give a picture of a rel i 
tivelv new field in the worl of the Co'onial Medical 
Service In Nigeria a system of hospitals dispensaries 
and their ancillary services has been established and is 
being expanded in the larger cities and towns ,.nd i 
considerable amount of preventive worl has also been 
accomplished again largely m the cities and towns In 
the rural areas which are vast and have a population 
of some 20 000 000 much remains^ to be done Until 
recently the Siaff available consisted of Government or 
native administration dispensary attendants and sanitary 
irsp~ctors who were given what sujvcrvision was pos 
sible bv a medical officer already more or less fuliv 
occupied with the curative and preventive worl i 
hiv headquarters station The sole cxceptiop s ih_ 



j\s n i')M 


MI 


\1 III t P UMIS M(il KU 




Slecpin}, ScrMf i (unr nni-i 

^lc^^.rl^cil In I iMcr II'). S) 11 .tJmp ' '' 

Mtl ctiliu (l')IM -ninth In > p'o r itmtsc ” ' 
Mir\c\ rcp^il siir\c\t ir) Irt. then 

|ioph\h\n inil inli I tl c tlciruuc hn ii the li 
2(1 \eii\ hri'tiihl hum in Ir pnin oi imn iirul tmilfnl 
I Ills ^rr\ll.c ilihmiih n iiiuIct'i'oS i \ in ti* i!ii*i— 
in riir il m n ti'iili icil it\ niniliei !ii ihr ei .* ii 
'I.-! pirn nl i\c\\ irriv m the cc il jl i n the n ( mn - 

In l‘)t' n pirt o' the 10 .eit e'e -lO,. t - n t'>i* lo 

Nijcni I lien nil il ee w e n-n (c pi ! to ije,) 

III i)or ctnie iiiw iiul epi !.• iiu i' leu'i on m Uf li 't 

Oril III lll\ V ilhi! l’ e i,'ilflii! |e il i ih- i r ir 

Is non I It 1 'n n the 'Ich il I le'.' t iit it 1 n i ' i 

lercil I iiiitl sit'i till < h'e St p n S li,- i S- \i » 

I he inte-itio 1 ni to h ir P pin < i i i n. o 'e 'o' 

enh ot the hi e po i Ke* I i.h 1 ! L ' ’ ' 

hue 1 iiinin il o'luc i nip^ i He 'e it le\ I* \*’( ) 

IV to 2 I'fen-M III! dll e > cleiVi m' i- ' i ' 

lithe jiinio ltd' 

\1 p Csr It ei h* t 111 hise I le i I il ev* '•t 1 r e 
n no I Ihe Ill'll o' opei iti ' i. > c i i' nl i r 

l>pe o' con iln mil cIi i te o* i o, i .1 \fii > I i 

iVlIeiiic north the Vno'o i ' llo in i " li i ‘ i li 
111 nili-»le-i.rl co 1 'itio 1 pi i'll tin 'illnvrce 
kill vlumliiu Ilf' I’l leni I’rvnn <• v iit o, A'ei p i 
on the III! 1 e uiti, I i, ]i p’llrui ni''i i iv .1 i n i o, i 

ind p iril 1 eNo id the e s itp ii i i m t’l too ' i i i ! e 

'Uipin. M I iiei nut te eplr i e i' K - tc > > 

pttihlenn In ill* oid'c! Mu'd.r licit Iitl'rt in 

till Uc vile milt notV 111 111 lid 111 ni > s i vd o c' d 

eoitnlri Its note n denfi' It o' In it e nei' 

null hn heeii c 'nhh tied ii M’-ol i 1 1 I’lmi e i > t'l 
ot I ijin iiid to Itie Ci 1 itie ( in etoii n ii iil < 1 - iiaI- 
hclnic 1 the ti' nt il f iin to I'li it d it e 1 -lie Itc- tii-h 
Inids of It linen 1 nhcic line tie ds of cittle me p i 
lurid I lie Inn lien tiiiil mil t i I > V itti -i 1 1 to Kivet 
I’loiiiiits III tile Nif,ct d It to tent ni niiphilii i i 

hfc 


A prim irv dull of tin units is is lii n oiniii 1 title 
suj , ested to issist lov d s ill in loliltolliin I p de lit s 
Suite l‘) Ifi lliti hue t'"cn i died o i to ds d mill ' elt > s 
liter ttlipsiui feitr sin illpo\ md icret. o pm d (cie 
In I‘)i') mil I'^^tl i told of KHttUd i ises of le e’'to 
spin d fmr nerc rcpnrled md m llie former \eir tlie 
It^mi" linn n i\ trmsfcricd i distiiuc of '■on indcs to 
iisist III lilt imcr(iiii> I r msporl i m mill in lire 
niid'i it ollntrs c ir mill lorries md I it i ii |oi si df 
md Li|iiipnicnl hut mil hi hi till riicr ijile hoise 
or on foot Ihe list method if m e iili slut is in ide 
md the tret eonipletcd hi mnoiih) lit or m eiih iiioin 
mi is proh ihl> the most cn|iii ihic foi those nho hnd 
dthihl in Ihe einitilrisidt nhieli ihoiinds m iiiteicsi to 
the n ilnre loser 


Ihe other prmeipil fuiieliiin of the umis is to ississ 
the mcttleiiee mil rilitisi iniporl met of disciscs in tin 
ruril popiil ilion md to diiisi nii isuris in iinst Ihosi 
ivhicli ire e uisiiii most d im ij e to Ihe pnhlit he illh 
As in most pirts tien of the ciiili/id iioild our I non 
cite of disi ise inciilenet is f mill md is hisid niiinl) 
", P dienl mil out pilnnt niiudmiis I nii 

lienee tin be tmtiil onli h> e\ mim ilion of Ihe 
■mle popul it.on or of ,ii nliqu He s impli sneh i s.ir 
cy IS i escribed here I his inlorni itnni is ol Inst impor 
tmec to the economics of , toiinlrj OS of uliost 
populition ire pcismt fnrmers proilutiiii 
pnm oil cocoi bcnisccO ett 
the country depends 


. t,iouinlniils 
on iihith the iiedlh iil 


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111 iilnli d ii 11 c th'ltilciOi lie c\ 1 iiKs e- h 
p s 1 lot SI ns o' Il mil del nt,i Itn m no u m 
llSls s ll'irs Icp Ovl ukets Cle llll'lSe-l Cudc CO 
piiinnts sue II ilioi' ele lli mrs eieh eitd mth 
iliteeliiins lot liK'tili'ti I iioln lions md In ill tl 
tl ristiiiinl I’nrd ih ssoriKii ol islon Ihcic nc c i fc ' 
It ( liinl tl, Ihi nisei ol the mo i p oil's. oiii VIi's>cm 
It iders Here cvniiiniil in ptii les I chiiul i sp nitcil 
ntilsstccii ill ulnll III lies "eic e\ 1 mnnt to icnereil 
ihseise hchiiid i siniil it sateen \tlit seemi Ihe n cvh 
e il olhecr Ihe p-ople is nt m i leeond n utim lO'ni 
nhite iieeinnion md tci leein ition ire iloiic 

lilt sceond It iiltiu tooiii lenis to the liriest shelter 
oiir to ft 112 2 mettes) loin I his is disnlest into 
lihoriloii md treitmenl scetioiis tin litter subdiiidcil 
into I elciii uijiilton seelion mil i ihili drc"tni 
iiiid ( mir il scelioii I il'or ilori iniislie itioiis in iii es 
sirih rcsliicltd to sihil is priiliiibli undir licid eon 
dilions Oust hell iiiul Ihcs i m proii triun to tin 
liniper to siple teehimiui nnd to the pripiiiition ol 
spieiiilins 

At 1 iltliilid sunn the louliiie inii'tii ilions iiinK 
on ill Utenihiii iri net lilood him It) nimulis st mud 
Ihiek him (I itid s or Ciitiiis 1 ) 10 mimiles stool uriin 

tested lor ilhuiliuiuri l if positlii the v|Hemien is 



Jan 13 19SI 


MFDICAL FIELD LNITS NIGERIA 


ByjTOIt $7 

Mro CAL JOLAVAL 




Fio 2 — ProAinccs m Nigeria coAcred bA medical field unitA Aofr — Nijrcna in area is 
greater than Prance IlalA and Belgium combined in population greater than populations 
of Canada Australia and Nca Zealand combined 


centrifuged and examined for red cells and schistosome 
o\a haemoglobin — Ihc Sahli method is row replacing 
the Talquist 

In addition in tho'c with suspected glands sLin lesions 
siens or sAniploms gland juice is examined for tnpano- 
somes skin snips and nasal smears for Icp’-oss sputum 
for tuberculosis and urethral smears for gonococci Red 
and Ashitc cell counts cmhrocxfc sedimentation rates 
Ide tests and examination of cc'cb osp nal fluid max 
also be done On a busx dax si\ microscopes max be 
manned continuouslx 

In the thcrapx section standardized treatment is pxn 
for trspanosomiasis saws sch stosomiasis scabies etc. 


and a good deal of general 
medical XAork is done Dental 
extraction is a popular sideline 
and one soon realizes xxhat a 
fallacx It IS that the African has 
good teeth Apart from the 
surxcjLCS for the dax there 
IS iistiallj an out patient iiinic of 
strangers, niostlx canocmen 
and traders and of xillagcrs 
from areas not jet surxcjed 
The eases seen at these out 
patient gatherings are most 
xaricd and interesting 

At the back of the clearing in 
xxhich stands the examination 
shelters IS a row of in patient 
huts, xxhcrc the scrioiislj ill arc 
treated Some arc on sulphon 
amides for meningitis or pncii 
moma — the latter being surpris 
inglj common m tlic cold drj 
season — others on penicillin for 
ostcomxclitis xxhilc at Cliinkai 
xxc had a senes of eases of acute 
amoebic djscntcrx xxhich re 
quircd emetine under supcrxi 
Sion One of the huts is gener 
allj reserxed for minor oper 
ations performed on a tubular 
steel stretcher raised on two 
boxes this makes quite a useful 
operating table 
At the conclusion of a surxex 
two reliable dressers remain be 
hind to complete the courses of 
treatment These arc made as 
short as possible to reduce ab 
scniccism The intensixe one dax 
nco halarsinc or maphar 
side treatment of jaws is cfli 
cicnt and non toxic trial is 
being made of miracil D m 
schistosomiasis dailj pent 
amidtnc is replacing suramin 
( antrjpol ) in trxpanosomia 
SIS although all cases still gel 
trjparsamidc scabies is effee 
tiscls dealt with bj tctmosol 
in palm oil 

Before starting a surxex a x-arx 
ing amount of propaganda and 
explanation is required The 
medical officer or superintendent mal cs a prcliminarx 
propaganda xisit to meet xillagc heads and elders Dur 
ing the surxej specimens of xcctors such as tsetse flj, 
lice and snails and magnified coloured pictures of trj 
panosomes itch mites filaria etc are shown and ex 
plained chiefs and elders arc shown the larger parasites 
filaria, and schistosome miraadia under the microscope 
and a good deal of simple health projxiganda is done 
In the near fu ure a section of the unit xxill be stationed 
m a special dexclopmcnl area after an intensixe sur- 
xex and an attempt wall be made to control the more 
common and deadlj endemic diseases in this limited 
area 




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were ex ttniiKvl Itie ili mei in w)in,h tiiej %'i > 'd i 
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fhcfunviioi itttl Use- \Mnl o' c Si t ‘ * 

Ijniu *irc t!w CTit rJ ind in'’ r of it r ti iS \ « t \ 

Mine) of C hml ti Ooin I in P nu- IVowi r ^ r pivrn 

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ifvchcvl fio n Hr J I *ts.|rctif ri> ! aI <* ,r jf * 

in llic ficlil from Mr J Ci Me ml ifiJ ficM o > i n. r» r v 
iiul til tl'id of ll»r H ntic I irM I'lnt 


Ut tl PI s M 

Ihrifnif f< O ffV I'M rnini A n Ur* fix U .,*.1 

t CMcr H M O (lOlSl H Afr /net 7 10 

McfcrlLhic J f front / ^ /o / \fr/ //n 41 44* 


Dr J Greenwood Wilson nicdu tl ollivcr of hc»tlh I»v 
Cirdiff writinj m the December 2‘) issue of ilie \Juftxtro 
Journal comments on the c-iunous sun n u)r \silh lU (i 
N iccin ition m Itriton Onlv sclctied luhcrudiwis lonUcl 
ire inociil licit tnd cvcr> thild so irciinl niusi hue Veer 
M intoiix itsltd mil mini he iw {> from ill ris) of liiheaii 
tons jnfcclion for tlic six uccts before inoculoion iiui tin 
six wccK ifitr I or ihis rcison !oti( udlioriiics luve Ud 
'"x* opcnmi ilie nccosirx tcM.knti i 

Dlin i ^ ^ 'Cbuiid IX ilicir icsrnitxihihl> Ii 

Cmml'^hn’Vi ‘ T V'"''"'" " ‘''""'’titcl b\ th, 

mme mn ^ and ilmoxt »n> metlK il nun enn 

rus fie bclitvcs it would be much liciter if n f r' ilj i# 
' resr„nMt,dd> of’ of t'^U U." ^din..:;^: 

- ignnst diphthcrn 


Reports of ^Societies 


loini'ooi stiuK \t tNstrn 110 N 

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s SI » * ' if V n \ c p t fs 4 . f ' -*»* - p t 

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I r ftirP e I ' vj t t M ' * - P j **' I! ( ^ 

\ t i Cxi X i\ t c *f if- tf 1, ale » R »f I 

iriur, c'sfc’n o < sbar i v * I w - 1 i ' 1^ 

I I Hsf \n >l e ip w s p d \ d*Sis- 1 s> f* r - ♦ Swf 

\ hi h ssoid I , ne a Ich it S fj-i I s^jp -i tr I S * (a 

tills h it no’ Kv I I V * , ^ s' vl t u\ d ii N sit ii •'s V e k 

f se-dir^ Sof liid 1 I ' ^ ** ! u 

ret* »l h > I f rn meP (' t» ; uU«P d n tv frs i var i 
s'thcf s »ufi.es 

f \ as sh nso to Is of \ itue ir t ^ itiOi tl - ps'stti m ti” t 
M c i ( fi n ttomm ihvioid tnsiu ii itnnn-l px>M u'nv fv 
ibc ps’sl op I Pivc s ucs on- i» it si fv utten e' were st 'wn 
to iKsur in the p\Mmtd4l b'l " later d t dvs m (tor’ xi t 
bsbmd tlie tuslici 'ird in llic inrvlnsimun 

Hitve ci'fs of Ihjn toxKi MV rnli imtcvl wjiIj T nwbi 
ttmcs t>f * I were invesppped llir first pdien: Ind rrnn 
rent tti\fs»to\ist»sts mint >cir after {hvf»» dcvlonv Twi 
motuhs iftir treitmcnl traser expenments were repeated 
the th^robf tissue Ind shrunk md tfie urimrv ewnh n 
hvd instxncd sluvwln^ tint the tlnroid fun turn bad b*en 
IcnctkuUv ilTctlid the hndims corresponded Iva the 
cUmevt unprwcmeni Un sevmm! pitient had a to\K 
utcnoini which caused c irdnc failure She did nol tidct 
iilc lhu»uru.d 1 was jx^un pre operdneh wdh >ool 
eflcti n>c third piiicnt al>s> hut c irdnc future due to 
ilijrotoMcosis She too Ind bcnctdesl from trcitment wdli 
I nttliou^li It w IS loo V iris to jud^c if the effect wouM 
bt pernunent 



Jav 13 1951 


Correspondence 


KnichlsbndRC Plague Uospdil 

Sip — At the moment of anting contractors arc bus\ with 
cxcasations and stonework at knighi^hridgc Green half 
wa> between Harrods stores and the top of Sfoanc Street 
A notice exhibited on one of the trees intimates that a 
garden is being constructed there for the benefit of 
Londoners Tins small triangular open space is cxacllj 
opposite the establishment of Messrs Tattersall the mart 
for horse sales The tradition connected with if is that on 
the site of Tattersall s there existed m ancient limes a 
lazar house or leper hospital At the time of the Plague 
of London in King Charles Us rcicn this leper hospital 
then well outside London was either whollv or partly cmpt> 
owing to the fact that lcpros> was i disappearing disease 
in Tngland It was accordingly made use of as an emer 
gcncy hospital for plague eases from I ondon Most of 
the patients died and their corpses were disposed of b> 
digcing a hunc pit outside the front door and shovclltnc 
them in with quicklime When the pheue died out it was 
ordained that this burial pit should remain for ever un 
disturbed for fear of starling ofi the epidemic again and 
so It has remained unbuilt upon to this present dav After 
more than 280 years it is improbable that an\ H pesus 
remain in the sod thouch conceivably there may be rats 
in Messrs Tattersall s premises h> whom the infection might 
be spread if there were any The inhahiianls of knights 
bridge can be assured therefore that they run no risk from 
the disturbance of this once plague inseminated soil in 
any ease the hallow digcincs do not seem to have reached 
10 the stratum where the bones may he presumed to exist 
—1 am etc 

TunbtidEc Wells Hesmv UomNsos 

rxcrciscs in Uic Hatli 

Sm regret that Sir I conard Hill s letter (December 30 
19^0 p 1494) docs not enable me to reconcile my opinion 
of Ihc cnergv value of exercise with the statements in his 
article (November 18 19^0 p 1153) to which I took cxccp 
tion llui since he* expects me to study the pamphlet of 
Mr Togna (fie oricinator of the exercises I feel it only 
nchl to observe that I would not have ventured to cnUcizc 
\n eminent physiologist without prcliminarv carcfyl con 
sidcralion of the subject at issue 1 w^s one of the xerv 
lirsl to whom this pamphlet was submitted and Mr Togna 
himscjf demonstrated his exercises to me eight years aco — 
1 am etc 

w 1 Aix)irm ADR-sitv'ts 

Atvpical Pneumonia 

Sir — In the articles (December **0 pp 14S7~<>3) 

by Profes ers C H Stuart Hams and S P Bedson no 
mention seems to have bc^n made of the fact that some 
sufTcrerv from atypical pneumonia thouch non svphilitic 
cue positive sNphihtic scrum rcac ions One would have 
thoucht the fact vsorth mcnluniac because even now and 
then a re-cat su*Tcrcr from this rcspirato v ducasc happens 
to have his (O' her) Hood tested for svphilis and the 
development or not of p'*».ls of v'om for the suTcrer 
depends on vsh'thcr the rredteal ai’c-'daris in the ease 
know This cause ot roa specific reactions to ssphihtic s'rwm 
tests D fid'*atU 1 succest aUo that the svphihtic scrun 
tests micht he a m'^ans of d iTcrcntntmc so-^e of the group 
of co-'ditio'^s row classed as atvpical p^-imoma 1 h^vc 
bi tied in h- e h-cni sc the d' enp u n bv p o‘’evso' S u^r* 
Hams seems ratb-r cV‘'s-l\ s to st eases quo cd 

b\ Os-^ord arJ n\s T n a paper read before the Medical 
Soci' V fo' t''£ MuJv of Ne^—cal D scases in Ju"- 19-“ 
cn 1 t-d Th' I ses ^rd tb** I i'^i-.ti''*'s of the Sc'um Tes s 


Pirrmt St; 

xfforrit. BviL 


for Svphilts Referring to atvpical pneumonia in ihu 
paper we said 

Bui pethapN more mtsleailmg dan the conditions alicads 
mentioned is a iransicni bronchopneumonia whu’i apparendv 
pucs nsc to vers little consutuiioml duturbancx and mas cause a 
positive rcaciion persisting for tw i months or longer PirtKular 
attention was dra\ n to this cordiiion b\ ransom (l‘)‘*0 who 
reported positive reactions m three undernourished whool 
children and oac convalcwcnt from m'^aslcs who were sufTcrmp 
from what was described as hilifugal bron hopncumonia in 
which radiographs showed a streaky infiltration of the lung 11 c 
scrum reactions persuted until the radiographic appc3rank,c had 
become normal— that is for a number of weeks ] anconi quoted 
Porssman (19^2) as having found only five false positives in 7 711 
general clinic case* but three in fix eases of pneumonia and 
Poclcls (19t‘') found four false positives m 206 conv descent 
meas’es cases f anconi s observations were later confirmed liv 
Ifcpghn and Grumbach (1941) and by Jahnel (1941) Ilcrelin 
and Grumbach had 18 cas-'s of atypical almost afebrik pneu 
monia with the irca) v infiltration mentioned bv 1 anconi and 
positive syphilitic serum reactions md Jahnel reported 11 similar 
cases Both hts and Heephn and Grumbach s ca es had a hijh 
proportion of PfcifTcr s influcnra hacilli in the sputum and their 
^cra strongly ''gglutmatcd this organism ft seems possib'c ih ii 
Pfeiffers bacilh may l>c capable of provoling pseudo svplnhtn. 
scrum reactions in patients with labile scrum 

Both Fanconi s and Hegehn and Grumbach s articles arc 
illustrated by radiographs — I am etc 

Ijondonswt I w Hsrbisos 

Rtrtfrsns 

r*ncom O (I9VM SrA-r/ mrd Wsch €6 S21 

! omman 3 (1932) Acti Mtd D^od dm Set A tS i (ref 

Fancom) 

Hamson L W andOvmead T H- (1943) Brit J >fnfr Dlt 1# lOS 
Uegcim R and Onjmbach X (1941) 5rA**«'i mfd \\seh 7t S7g 

Jahne) I (t94l> Mm H tcAr SO 10^ 
rocUU W (1933) A /n Utclr 12 <31 

Trcafmenl of Lumbar Disk Lexronx 

Sm— We must all be grateful to Dr James Cvriix 
(December 23 19^0 p 1434) for bringing some sort of 
light and order to clanfy our ideas about lumbar disk 
lesions I hope his remarks on the importance of lumbar 
lordosis will be widely noted and followed Here 1 just 
want to mention one way m which thev art at present 
often flagranllv flouted 

1 do not now frequent large hospitals but I find th it 
surgeons still have a habit of directing that where a patient 
IS bcinc anaesthetized for a laparotomy the hands should 
be placed underneath the buttocks This reverses the 
normal lumbar curve under the anaesthetic the spinal 
muscles relax ind so the lumbar spmc goes into marled 
flexion This IS I believe the rcison that numbers of 
patients after operation — and especially when thev pet horrt 
where they speaV more freely than in hospital— complain 
of backache more than anyihinc cise It is of course still 
more common after the hihoiomv position 

Physiolocicallv 1 think that the right place for the irms 
IS across the chest or if this gels in the way of the surgeon 
thev should be crossed in the operation gown and allowed 
or made to drop bad towards the sides in such a wav that 
the town exens pressure on the thorax In p'actre this is 
easy to arrance Su gcons seem invanablv to say that this 
will impede brcathinc but the fact is that inspiration is 
caused bv active rruscaib- action whrh can casiK lift th- 
wc»'’ht of the arms while expiration is almost entirely 
pa sivc so the weight of the arrrs on the ell'll tends to 
make It more cfTc'tive and helps to count-Tact the cxlr« 
incHcicrcv of expiration caused by relaxation und'*r the 
anaesthetic The ret result is to imp'ovc and not to inter 
fere With re piration A snail cushion should be placed 
urd'T the lumbar spine to prevent it flattening under th'* 
anaeslbc ic 

1 cannot chim to be an exp'^ on this subject bu I have 
vet to b-ar anv refuUtion of the simp!* r^'chanical and 
phvsiolca cal pnmples on wh eh nv remn Is arc bj *d c r 
to see anv v.ilhn!r'*ss to carm out the si-'’pb chan"es ir 
te^briau* which tbev su*''cs* — 1 am c*c 


CORRESPONDENCi: 


\\ N Irs) 



‘>0 J\s 1' 


c ntuu M'O' !>i Ht I 


fi/ - 1 
^ ti t- i 


SlK — tn lin Kvcf I \tjutc D riWr2' 

p 1 cmpfji'* C' (f c ' U ^ \ 't^ \ "Ia 

p»’i’;.c *ur». Maupn^jHr Ot t '‘i “itc i.\ >’n t‘ ii 

jcrertl ifKtKt* tftJ «(» i p ictuc v( (^caAjC ■»♦ r f* ? 
I0'» J'cs i'f til imo ''iK I '• n mil if ' <■ 
lOtfiiifc imJcf ihn linii rihni t n ^ i * t’ ifj 4 P I h 
tol|j\ lrUfvl’^tll nfiif Ipit p'ci i’ > ifrif- fi 
Im luwl ttlir u ii \\ \> icriiin ti imj ^ l^f t i i'll 

noMbU ilioijspo Mrtv rcn i(n c* 1 

tu'ns U<vMr f ill li»t b j nnl% c I ' I to %♦ oc 

i.ir ill ilw, e\ct> d^s i. m b* '* ^ i’'» l' 

of ill'- cir 'ri\ct> - i I til til A> 1^1 I t cii I *J t 

like j ru'ni\ i\ liic i.oMtn o'^po !cii’o»» il fj * f o ll 
piOilu t»o 1 o' 1 ri ti mI MfiVrri im I) b i-c pj I ** U 

i iti \N c t. M Otl" if 1 if i ' t li^ iM t» ’i <■ * *''1 

luk't ird '>lt ip'' I ' { ?i P / t* ^ fil -» I t » ll 

f i f'lit t* c /» P' I ^ i'* J ll '* cf» r 

mii^h I It' ». ll - Ir% cl V * il r fiT if f ’10 a - > 

pr R ilioncr m \ ol "nc « 1 b»i f‘> i» 


fill f Ri {I * r I '''f ti 

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tt fc 1 ' 1 tl’ if i t < ».4 1 

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nnmpu’i Cv' o i c bitU ll r j iM rcf f 1 i n i* t I ’ 
ll " Ihv*) tf'tb n 1 o’ -fij in p v- f> ill tv- < f { 
iSjtll t (1» V ^clioll i fi ll - tj 'b t III I *l <i * 

if 4 bitilcfil ffi 1 1 1 h 1 lI'C I f « i r 1 *- c I 

intnnun kcJ t’ i uu •* <. f fl '* ( 


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Ji»ini m mipiil iiion bn I cen an! 'till li 4 *» r •‘I »i 
cnipjfici! «>tuii\ ihouib tbc ll co > tcnittncU ul ti cl \ 

J MenneU (/oif r '/<ff iri/'/ //Off 'ol ^ 1 p > inhiin-* l| c i \.vt 
fence of III inirn iiiivulir tlticoi n ti \ct me t p o' 

irtictiiir iirfivci opposed t«’ <’nc iiioil cii vioiild 'cem to 
iccoiini for most of ihe phcnofTic n iit-t \s»ih m tbo ficM 
! ini etc 

/< Hof tt N I! } isiuoo > 


SjR~In his inlcroiiiii ifiulc iDcccinKf 2' p 

11*11) Dr J C>ni\ olTcr^ locful uImvc on lunv to 4%OHi 
the conililion iml how to prvvcni fc\.nrfcn c 


Suricon*. *ir iltcm\c(\i,\ ionKliinci ftlTcttcd I hsvc I o! %uc 
illjct of <tfinci conMifcied l>) \n onfiopictli Miij-con t»i hoc 
Ikcii probibU dm lo i doV pioini it n 'tml mm> nlM k> if 
lumlnfo winch I now bclicic were noi piitliucd bs lo al chiUm- 
or otficr Mich cnii'c^ hnl weic iiNo of dok iirnni ylotlowuu 
\onic inoniln olf dni) I j 01 Midden lw|nJc^ of nil mn k. of 
tumtnjo dnnn) iht tour c of out of lli-' Imi opcfttinn uIirIi 
I ptrforincd tin opcntion hsiiOj mote linn an lunir urn! wlmh 
incMnlily iniohed n tonsufcrnhlc dej ttc of >pitnl flexion I lux 
impkisint octiiffcncc nude me Mopctl dj »i ifu ifinmrtf r<»do fo 
had caused lilt pirinl Intkviud iloplucincnt of n initlro 
pniposus I w IS tliotoinhl) tilmncd for I fnicd ilni 11 furtlicr 
period of incipicil) w is nbonl 10 bepn j decided lo ir> Ibe 
ciTccl of extension of ific spmc by wtijbi A folded lowcl sv is 
phetd on die lop of a door and bool mj no finfcrv osci ctii 
1 hnn^ for a few mniules and there iftcr tompleicd die opci luoii 
without further trouble fhis imdc mt rtHctt low u cfnl ii 
would he (f every sur{ con s drcssini room Ind m n a ibicc fool 
icnpth of liorirontnl bar At the end of a nuirrnni s opciaimi 
I short swin^ from tins nw^hl wUl pivc n disk which luid hctomr 
pirtidjy compressed a tiunct to rtadjusi itstif I womicT if 
On I r considers dnt such a simple meet of ttiinpnHiu miKbi 
hnd favour widi mdustml medical ofliccrs Snitt the shut of 
my experience 1 have been careful wlitn doini similar operations 
to piuse from umc to time and to stand in a Scry trctl posidon 


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Sir - U ( ans aid ' ai ’ar at *t tn c- s » * <d 

irt ll c da> (4 s!-\ SOI (*' d f tdi ' * aix t-s* ' *ap^s 

I tilt S 4 » ll ip*nird i s ll it s VI fvr> » ' l' si^rd -a** e w vs 

tv iiin''n cd in S erdvf J w’ ' m \* *id 'lafv 

l‘U** Dll ifiulu vxcie r Ibi'ci tn t* c ibiM //r 
Soir/i' I'Jt; II .r-l We < rrc <t»fp (’ vl f ef* c 

I Ole I> I'clci O Ic Mils tv’Tt cnl ft> c iK? U 

p |V l> dial no one '*> Dr bn j icf), cd lo assess t ^ 

psilcniialdics of this niclh wt f*'r vl i ’ sim d p C'vW e v 
t ifdu d nt r mliti \ We rcv illcd for eimuil c\ini‘'v 
lii»n tio\ vMvtv ibo c vsl 0 t nc in si < 0 n tl tai* t ' 'i d 
pitUitc bol lU additton ill those v>ho j ne a bis on siivvcs 
livc s*I previous ibcuiuali it fe tis* o' bcbcviii. lb > 

hui he 111 di case It vs n bopctl in ibis vs ty with d lutni 

lUum of intonvenicpec lo ensure lie ilcicstion o' csrdia 

II tuutu ildics IP p iticnis un iw ue *'f ill eviMint- 1 can if u'p 
Old) the rcldionsbip between the ruhofrtfb 'ind citn >1 
lindUH'' O’ lelcv vni Us Oi live ills uili le Tlic nts d 
tonitno)! t Mists of rci ill on svsvsuni of \ iiv ai noiu’ni'i'C' 
were jcncrd tudnu cnliivetdcid pionunciKc of the phi 
lUonirv uicr> sir ii> lileiuni. of die left bciil i oivi-r 
pro ninenl touu unfolihnK of die aotli brouieniP) vf 
die btsc of di- belli itui tlexirovardi 1 of dice die 
c stumoucs’ vvctc tiidus cnlirjinienl jts'ntinirKC of ibc 
puUnonm vnciv slnvlovv oul ptomineme of die tonio 
or the ll*?l/s roulint i ri\ ptsluns of dn chest in tiie 
pcrunl under review K77 wjib no luslorv of licul disc we 
vveic cMinuncd !>iciijse »>f one 01 oilier of dusc Idler i n\ 



11 1951 


CORRESPONDCNCC 






ibnormiliiics and of these »»-♦ were found to ha\c orginiw 
vnUc disease and 8 conccnttal heart di<''n<c a higher ina 
dence than the 5 cases of organic mKc disease and 1 of 
congenital heart disease found in the I uerpool sursev On 
the other hand the hichcr incidence m our inscsiigation 
ma> he inHacnccd In the fact (hat n hivtors of previous 
rheumatic infection was also taken into account Indeed 
of the 44 eases of organic valve dne sc 23 gave such a 
histor> We hive considered cirdiolonical ease finding b> 
mass miniature ndiographv to be sufitc!cntl> worth while 
to continue with this part of the service —We ire etc 

Atrx MsarvN 

rh ro AS Rons 

Fniotions and the Skin * 

Sir — The cnlcrn for the <clcction of patients with skin 
disorders for Ircitmcnt bv abrcictivc techniques (December 
9 p 1300) would serve cqinlU well for the selection of 
patients for inv ps>chiatric trcitmcnt The skin conditions 
described bv Dr H J Shorvon and his colleagues were 
m inifcst itions of psjchosoin iiic illness and called for treat 
ment bv normal ps>chntric methods The f ict that abrcic 
live lc''hniqucs were used is neither here nor there Ccrtainlv 
there IS so far no inoicalion for the treatment of psvcho 
logically determined skin disorders bv i specific form of 
psjchntnc therapy 

\brcaclivc technique is n form of psvclioil ernpv and not 
a minrcuvrc divorced from nircoanihsis Patients should 
not be ibrcictcd mcrciv in the hope of relieving tlicm of 
tension Tension is relieved hv giving them an opportunit> 
of expressing their emotions Thev then become more 
capable of discussing their problems md viewing them 
objcctiNcI) 'sarco anilvsis is a useful method of giininc a 
more rapid insight into personahtv and the possible factors 
underlying a neurosis In 1941 I discussed (l^rca 1941 
I ^07) the m in ipcmcnt of cvccsstvc ibrcaction in the course 
of n ireo an dvsis md 1 do not vet ulvocatc uncontrolled dis 
eh irpe of emotional tension Shonon and his colleagues 
on the other hind cmplnsi/c the degree of excitement pro 
difccd under drugs is the item of greatest thcrapcutit value 
md thev endeavour to excite their patients even bevond 
the naturil and sponl menus rclc^ise of inhibitions which 
occurs during n irco an ilvsis An opportunitv to let olT steam 
will relieve tension md relief of tension may help i 
v irielv of skin conditions but bstmi, benefit can be brought 
ihoui onlv bv the scientific applicition of ibrcaUion 
Dchbcralclv to distort events m the patients past hislorv 
to produce f re Iter excitement or anger ipp-ars to rrc to be 
verv unjustifiable and possiMv dmgerotis SIio^k tactics 
m IV have to b idopIcJ m ome eases but sureU should not 
be idvocilcd as a routine practice 

I »m surprised ibit sine of the cases referred to in 
Di ShorvonN iriitlc were trcitcd bv prolonccd and deep 
sed ition befoic tbc ibrcactivc method was ittcmptcd llcivs 
edition I inv iTiabU toxic in sorre degree and as a treat 
ment is uMiallv LonlniT dnted m psvcbologi al skin 
di order Tbs esc histone vscrc n ost inicrcstirc but 
dinonstfiicd lie valti- if rarso analvsis r”orc cTcUivclj 
tin” lb It of ibre ctivc technique — I •'m c 
{ - u Ti t IN Sn s.o» 

Containers for Svringc Sicnii/ation 
Su, Tlic te ill iti'»a vnng- bv dn hca! as c-o** 
mended b\ lb MKC Report t f 1*3-2 is stu! in th s c< t nt v 
tire na bs.1 ‘ f ».b i c 'slKn v ’*''di ions p-nnit In ri '’“ir** 
t ho ~ al vriP'* sc v i c tl b r -“st pro^’em i t^-* o' 

pa kin. ssTir‘~c f Ta! al " d ^nb » •*’ nt* t re L,m 

It SO”! M" thi-.y*'' V e V q V " t ' 1 c V r- 

'IRC Pr^ t ~ s f 

- A--" - o is- I 

, , ra- ^ \ i-r w — b * i 

si ~ p— •‘-V 1 _ ^ 



K c 


Tb write has m dc an extensive trial of pa Irn" vair cs in 
gLss tubes rnadc to si7c so tl a each si/e of s>Tjn'*'* is con an-M 
wuhm Its libc retained bv a cotton wool plug and witli n gv rd 
over Its nor/le i ach s urge after u c is rcpl tcvl iris 
conl-incr and rctarncvl bv its co ten wool p u-* It is t! is 
prelected until rtturned for scninnp 

The disadvantages of tins m thosl arc 

1 Tlie cscc sue cos of tubes made to order 

2 Co ton wool IS pcncf Il> a nui an^e wlicrc ssnnces arc 
concerned Strands of the fibre can cau c j~.mmtnp of a wcfl 
fitting plunger and can prevent the atr tig! i fit of a ncal c 1 1 i^v 
if used more thin a few tim'*s create a cloi d of fine dust o i 
disturbance as shown bv blood films nade at tbc time Tl s 
arc a small but ccntinuous item of cost 

3 All containers made of glass arc liallc to break 

These objections arc met bv the u c of the extruded aliimiriuin 
containers illustrated here 

Fach svringc is retained bv millciblL clips fixed to a thin 
piugc sheet of ilummuim which is a sliding fit m the bixlv 
oi the box A rccdlc can be fitted before removing the 
svnncc from the clips so 
providing a stand until 
required Thts js a grcit 
idv mlagc on in macsthctic 
trolley 

There tv no cotton wool 
The lid of the box is seded 
b> »-dhcsi\c tape which cm 
bs. quicklv wrapped round 
the middle of the box after 
II c retaining the contents 
and indicating thit they hivc 
been used The boxes not being cvlirdnc*!! cannot roll 
thev ire much lighter than gl iss tubes of a comp ir iMc si/e 
thev arc pncticallv irdestructible md thev ire compact 
being little lonccr than the sire of syringe for which thev 
ire designed The abihiv to sterihre a syringe with needle 
fitted IS s,icririccd but this is myuay only salisfjctory on 
mctil nozzles md Icives the operator without a choice of 
needle Where drv heat stcriliz tlion is not ivailiblc the e 
containers can be used in an autoclave For this purpose 
holes arc drilled is in the illustration and can be afterwards 
closed by turning the lid round 

While these boxes arc verv much cheaper than glass tubes 
made to order they cost t htilc more thm those of standard 
siz'^s but this IS outweighed by their idvanlaecs ard Ih" 
fict that thev do not brctk Thev arc m ide m four sr/cs 
for I and 2 ml rrl 10 rrl and 20 ml syringes Tbes'* 
boxes can be obuined from Messrs I dw irds Surguril 
Supplies I td 8 Mo timer Street I ondon W J - I am ct 
HcrT.(ir3t2 Hen G A VlMfllfV'.s 

Amollicsia of llic Ne«I)oni 

SfR - I un nnnl i"tcrc^tcd in Dr G JacI on Fees', 
escell-nl article (fi'cemh-r I9'0 p I..19I B> i nc 
in;: the tclalivc Icn; ihs id Inche-i insohed howescr I 
fe-I that ht ficiire of i for the inf.n' re o'ipcc i 
exce M\e Pcferrir- to Mac—tosh a-d Mu •'in s //nrer 
fnr the ■iri rs I cii\! 117) followin., iR- crr'rir'cnl uhlch 
confirms F o-u lie s law th- an horn luUe the l-n-th o' 
th" tl he insohed nrJ n deuM; tic fow fair- th- 
ascra'-c pi" h' lo ''dii cation I'-n'-Ih in th" adiill _s ~ in 
1 10 cm t and in the inf r 2 in ('em) tlm oi Id n n'lf 
tl- res 'tarcc hi c in tie lat -r s t-_-l -n ii - hr 
It* Oefh till 1 i-h IS 1 'I p> h less nl r-ire f -ii c than 
tl , r._| — I _m c c 

r> * -1 a si D r Fi I s 

Baclenn in Jce-crcam 

Si- -Vi .n-o a mn (D ee-T- 2 1'<'0 p 1 .Iir-'- 

I , jw- j ,, „ _ , o' I- p -- - 

"s- '-—•'cji-ir I's.- w c I 

ss - a— 1“. -d I- S . -n V e. ' t* — w t - i -- p _ p i 
woes- p — -i-np-p 1-1^— pr > 

IS _ ' c ' — -eJ r ’ c‘ ' < r' - 

/ 






Ja 13 19‘^i 


CORRCSPONDCNCC 


y*TTr At J'* V t 


much comfort There ob\ on !\ i dcfcwt m the \virint. 
of the hlinkcl vjth the rc<-ull hn ll c p ^hortin^ 

Ihrourh T hcaw bbnVct \^hich dirc^. h in corijci uith 
the pirl*; ifTcctcd and \ hich ua^ al'-o touching the iron 
framc\\ork of the bed 

The ravh cleared comr’clcl> nl cn Ih" electric blanket \\ is 
banished — 1 am etc 

Uonnuth Tins PsFJ IS^ov 

I onj; Unihilicnl Cord 

Sir — A fev. months auo 1 iticndcd i pat cni m her third 
confinement FNcr>lh!np was norma! The umbilical cord 
measured from its root in the pbeent to the bab\ s na\e1 
4 ft 8 in (K2 cm) There was nc twist complctelv 
round the bods up oscr the front of the bods oscr the 
shoulder under the same nxill then up and twice round the 
ncc^ md a pood bit to spire llsrssards Jcllctt s \1i(U\ifcr\ 
•sa>s that the cord can be is sh rt as fisc inches and as lone 
as fisc feet just in a pcncnl wa\ 1 think that this ease must 
be more or less a record — I am cis 

Sjilrara n Cr If S''Jia Anrrt a ^ ^1 Writs 

Hclpint* the Ncssls Hhnd 

Sir — M i> ssc as idn mt ti itors rcspcctiscls of 
St Dunstan s and the National Institute for the Blind dnvs 
the attention of those of sour rcidcr who ma> be asked 
for ads ICC hs piticnts losing their sight to the proper course 
ncssls blinded people should follow if !he> ssash to tike full 
adsantape of the Blind \\clfarc Scrsiccs'’ 

If a persons loss of sight Ins been caused or aepns itcd 
h> ssar scrsicc (includinp cisti defence) he or she should 
pet in touch SMtli St Dunstan s 191 Marsicbonc Road 
I ondon N ^\ I which is responsible for suvh ci'cs 

Rcspon'ibilii> for ill those whose loss of sight is not 
attributable to ssar scrsitc— that is the cisilian blind — is 
borne b> the local authonties and th- lo^al aolunlar> 
agencies for the blind in co opcntion with the National 
Institute for the Blind Ncwlj blinded civilians should 
therefore pel m touch with the loc.il Blind Welfare 
Aulhonlv or should there 1 c anv doubt about the identilv 
of that bodv with the Nilional JnsiiUite for the Blind 
224 Great Portland Street W 1 which phdh provides 
applicints with an> information or advice thev ma> require 
—We arc etc \\ Mutw 

V-retin St f>jr sr • 

I C Come AN 

S'-rrctanr-Cr-'^al 

1 PiJ n VV I ''ail *5 Mn j f-r the V 

n'Kl! 

POINTS moM imTRS 

I nus-ual Prrsentitlon 

D A J Msnion M o I m d4s Is1 of No th bisi) wn cs 
l> n a rccT't bbo ir n a p mpara w’ i h '■rrei ed < r-i-^ 

fo w-tfil was vTusc ! I > hm a ton of fcsioa o'" - f«y a| t eaJ 

II :t p osovi to be dee to Pe rti-bt fc Cw.rm to s i*'- 

iM oat und r ll cMn t v -'d down tl c bs tl c co d wbchw ^ 

t M nsu-d ft c^rm "''d r-* V. Al I rPi tic rirM 1 -"d w-as 

h I w a*' ‘ N-1 nJ tl c 1 ft car i''C ba k o' lb" ^ard r a 1 c 
no k d'-sc-*'! o' :h" 1" d w s bw b^ d p cso" ed 

pn dt I i ' 

Mffca \c*minUir3tor ' 

n n D J iivs-is He " I wri "s We "-m n I sc n *’ 

- w‘ r' j u I 1 --C « ^ o 3 0 ^ 

"• J- I i" D C K Mt rds * . 

^ f "J s'* f t*--*.e , g 

^ ^ -J T k tr** t " i "'•n I — • *' 

I I w J * c w ' CT re--’" ' I> J 

^ -.4 » s - -r I — —v ^ ' -s r " *. ' 


Obituary 


G R GlRDlISTONt. DM IRCS 
Mr G R Girdicetone wlio ph\cd a Icidinr prrt in 
Itic idv^ncciTii-nl of orlhopicdn. .iirfcr\ in iIiia cotmliA 
dica on December '^0 need 69 Acarv 
Gjthornc Robert Girdlci.lonc \\ is born in Ovford in 
ISSI his father ""IS Canon R R Girdicsionc of Christ 
Church Oxford F rom Charlcrhoiise he went on to 
Ness College Oxford in I at St Thomas s Ilos[ilil 
sshcrc he continued his mcdicil cdiieilion h" ss is 
Uni\crsit> Scholar lie qiialilied MB BCliir in 19 IS 
and after scrxine as casiialls odiccr and house surjson 
at St Thomas s he ssent to Ossscstrs as i pirliKi in i 
surgical practice and there he imnicJiatcls came under 
the influence of Sir 
Robert Jones ssho rcgii 
laris xisitcd the hospii il 
for crippled children 
sshich Dame \cncs Hunt 
had established at Has 
cnurch It ssas as Sir 
Roberts liculcnint tint 
he plascd such an impor 
tant part in the founding 
of the Ccntril Council for 
the Care of Cripples In 
1911 Girdlcstonc becim- 
a I clloss of the Ros il 
College of Surgeons and 
not lone after the out 
breal of the first ssorld 
ss ir he seas appointed ssliile i captain in the R A M C 
to take charge of a unit for the treatment of b me and 
jo(nt injuries ii Oxford Those fess huts it Hcidinelon 
sscrc the origin of Hi. ssorld f imoiis Wingfield Morris 
Orthopaedic Hospital It ssas Gird'estoncs enlhiisiism 
md skill as a siirecon sshicti ssere IirgcK responsible fo 
Lord Nulficld s immcnscls p actical inicrcst in pro 
moling this hospital No less saluahlc thin the hospi 
lal Itself ssas the ssstem of clinics sshich lint ed it In 
lossns and sillagcs in Oxfordshire Uuckngh imshirc 
md Ben shire Girdlcstonc Irascllcd ssidcls to explain 
the adsantages of this method of org ini/ing onhopaccie 
care and it was after a xisit to South \fric Ihii 1 ord 
NulTield established m or hopaedic Inut there similar 
to the trust he formed for I’lc dcsclopm-nt of o iho 
paedic sso I m Great Britain and Norllm n Ireland 
Though the Wingfield Morns Hospii i! ssas the main 
interest m Girdlcsioncs life he bailt up a li ge o Iho 
paedic pr 1 C ICC •>n i was on the siafT of mms hospiLls 
in-IuJng the Padcliffc Infirmirs the king Tdw rd \ II 
Hospiti! at Windsor the Ro il Bii S irgi nshirc Ho pi 
lal I \slcsbirs the Sascrmlc Hosptil t Marl 
bis ou"h nJ the Ro^.rl Jo"~s mJ A""'" H mt Ho* 
pi'-'I nt Os sestr The Sm-n'-in Orllioo cdic \<'m 
tion cicctcsi him ■> co rc'po''Ji"e r"e'nh— Jn I'lsT he 
w„s ip-va a ed to ^c fi s o'! ' of o thopi--J ;s to K 
cst *'hsS d in this co-"'' t^" Ni Ti Id p o ts or hip o' 

o l''‘'p "di-s " Oxfo d He d J "o re"" 1 n p'o'c 
'o-c bsscse 'o' h* rcsmnej m 19-0 -r-' b - s"- 
co~ L n to tl c LM-S -"d 'n ihe M:"i ' oi Ih- 
s o"s In P-d ‘-e s-’s e'ec d Pres d of ' . P i i 
Or \ss.->-jj,iaa He a o -■ r~ " - t i- 

s and t'X " sals -d ^ s ba^', 7 1 / 

Ii "" -"d Jn " a-s p^S’ ish"J in I'l- 1 



r— 



94 J\s n 19 M 






>\c irt ifiikhlcJ lo A H (> iof ikr 

followinj (pprcxiitii'n \Micic\ri m t!ic vo Iil (> th«' 

p\a!ii. Mit^cr> Is pr all fi) llic mine ss( Ctuslte • me 

Is kninsii He \s i\ p I'minetil m llie stmU , <"il' "J 
pioiKers sslid <!i\ct( pul iinpuivn! -im! j spsi'm 'K m 
tircil Diiliin iinl the Di'tiimu' i Ih- pit pV itil 

nicthoils of the prime oitmito o! ihi • as’ il 

ssicitse ssliuli Ills ti ins^otiii- I tie livsi o* m niti f 
ihli ihforincsl imt ni) ireil hrititiii 1 'ui Hi '."e nl 
teieher icul ceTiitp'e ss is Si Iso’s't Jm s s ! 'e 
iiicthoils he stiishcil III eo'hl >f i!i > I m! r l he st n the 
sun Is i! pitliiei I'l i 'i ni of ihKto's u, O sis i> 'ts h 

Iso he o\ rs) to I) It I \t'i s Hull st • - I , i t v 

Itisshiirsli p oM.leit hull ssith in nr! ins' \ ,0 ’n* 

Ik is is esc itu 11 s tii sfs ile I u'l rtf in Os'o il 1 a i 

In no 111" Ills onls the 1111, vi tint u's s ' tl it 1 
h irneil there in the tre itii r o. i ip, ' lu i' 1 * 1 

ils<' the pull is' ileso'io 1 111 "'I'e 1 1 r o* 1 u iml 

ssitli sshislt US liter >c rs Ir t npiiei' aI! his j » is 
He hmt slf ss is i lorn sn j. ii SsiU stroi s s i ise 
h inils mil 111 iiir ii III line 1 u ' i tii'o 1*1' *' • e i' 
the lisiii| s' 1 lures hr S' is fnri ’un '' csii v ^ 

4 ils mil (Vffseli! il so It i"i ssill esj ti u aU f - ' n 

ol iiiciiKine ri ile 1"' f ep liu i 1 u i o’ \ <1 ’> 

levi to sslu h h- I ml' imru m’ i’ si 1 'i' ' > 

Hu s lllsll I'ei! I'eKlip Mil (i( o 1 n-' o,s A 1 

nictho's ssteniitis shn it oh 's m < t n f n' 

impsnt ml nn'o,Mph oi lut'r »ii'i s o' ll " i r cs 

jsuil Chi t' e o ) iiii/ itM 1 o* oil ipics'i '» II 

hospitil uni sh Us mil o i the s[ ro itt s'u ' o s'l t ' • 

he ilorie hr po' c 11 <1 is'o'e so itimn'i ti 1 1' *' 
peril ip 111 till I p»s! o' o Oil, ir Ik 11 t si’ s' his 
iTiosI ni issisc ml o ii III ll so itiO iim 1 1 ; 11 eo sr 

i/cil s\stcni of sitclhte shills rtoun ' ' r li e sn' 

from tile sctiti 0 In 'pit 0 ssh sh he sies’cl ii t* e 
Hxfotil ret lull ssOl lorn re nun the 1 1 nlfl on oils 
hit otlhoptcilis hill fo ill forms of psiiln* re Mini 
ssrsices I mil iiv I isi. oser the sontr ictii, \-sis st e 
sstiiis to cc the W in( lielil (lossim liV.r n n s Ms' in I 
hiitt util sprs ulirti Us heihit uiiliic isr fuilir < i! 
further itilo the sotinlies It ss is itu huu h'fo e I otil 
Niilli 111 fsll timlcr Ills spell im! } I'e the sp’emlnl u.l 
ssliich triiisfornisil the tcmiotit) hulnieiUs of the 
ninsisen tsscnlics into the f im nis \S ui} lich! Morris 
Hospit 0 of to ll IS A further resent Innetistion his 
sssursil Curilkstons House for nnns scus his home 
on the ontsl irts of the hospit il ns i s ilii ihle tcsnlenti tl 
tnnsxs iiul i pcirnuicnt mcmori il to his ntnie 

O !C G s nluis snlcif sliirislcr ( iiiiril him 
mmiiiisrihls fricmls Hs ss i 1 ‘>iperb lolfir ssl o 
nifht sssll Inss hten iiiiitciir sli mijiion if he liul 
not liiicl hslter lliini s to ilo mil he escclleil nt ill 
t miss rsiiiiiriiu 1 Issii tst mil issm its sonttol On 
Ins profession ll siils hs lies mic 111 iIik sonrss I’rcsuUnl 
of (lit Ortliop Kilts Assosiition WItn foul Nulhslils 
trcil nittfis ll htrisfislion s uik to Osfonl in the 
ninstccii Ihirliss hs ss is the oiils possihls slioisi loi 
the cli iir of orthopi ilis Mir(tr> ssliisli hs iissupinl 
svilh much dislinstioii lUil ifisr some ss irs of msts is 
int str un lit found it rKttssir> to rtiiirii to the lik 
of tlinit ll priclict and hospitil orj ini/ ition sshiili In 
loved iiid of sshich lit hid mult siith i brilh ml SUttl 
His loss ns 1 ptrson is irrtpirihlt hut Ins (,') ss irs of 
life tuivc been very full of ithicstmcnl mil nrll lour 
romun mcxiniplc mil cndurmi, inniicntt 
H J S wrilts Girdltsloncs lift ss is Iht Wiiij litlil 
Morns Hospilnl His desolion to it dss irftd ill liis 
other ichitvtmtnts uulhismmy 1 dtiils I his itiiiroiis 


{ft > ‘If iM’ I iir ‘ t t; ’ > J - V '* 

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on t IS life thus <1 h ti W h-n ss, l st 11 v s’ s' ''s 
ifirr ms irris si m I n Isiiil -sin ost tsisUe s its po I s 
cxtrildnl to iiK Ins protesliSs aril's fro ihl rt'" ''' 
Osford iiiil ss itsliei! ittentisels sU iiss 'Icp-. imti! iu 
s iss me liVmi rools in this sonniis sm! ns the lu"pt'l 
Ik hill foninl d Hiis mtmssts fiicnsUhip sn I dnh 
sonlisl J iss me the opjnirtiinils sd dososcime- o sv of 
tin most s\tt lordin irs tvtsonnhlies t'f ths nsssh d 
ssiirld ol to ihs Hs ss is i mm id sshom ms sss ntrs 
It ms tinn iimhi he prinid \s in ill nun ssl red 
udiiis his I K It t|udiliis sniiKil to te ho onls sihcnl 
dtfisls Its Ills simpluilv he filkil to impress ssipst 
(isi ll id' sissis mil hs Ills iiU'ik Sts snd rstirini ihspsS" 
tion he iKsri ill iiiKd Ihs risoi mlion to S'hish hisirsst 
iktds siiiiikd him His nu'sksis Ills ipiMtsisI to the 
slid hv his isliisiiij to hiss i nicmoml ssfiKs ikitMitsd 
to Inns Hisdiisslnis iinl iilim ptirposs mil 'inssrils 
loiilhsr ssilh Ills iiisipisits tor ihs'imnl itissis sssn 1 
sonrss of sunsrini lo him iiid sonisliiiu s to olhiis Hut 
ill Ihsss aitiihulis ssiit hXs sm ill urns implnnlid us ' 



Jan 13 1951 


OBlTLAR'i 


r i" 

1 1-- II 


foldtn hcirt Here Iij In'! suc*iitli ->1111 Jic oiit-.!andmr 
fcitiirc of In'! pcfAonalitj 

Girdlcslonc Ini been an example of a in n who Incd 
to loiL He loved God and all I’nl coma from Him 
He loved hiv conntrj hiv fn ndv ho raticnlv hia pro 
fciiion and Ins hovpila! Av a son maiion of all his 
olhcr prcit ifTeclionv he convcnlr ilcd hiv icndcincss on 
hii wife Im llic faiihfiil compmioa of Ins life The 
iUcim of crippled ind infirm childtea who tim> under 
hii care for more than fort> vears wck is their children 
and he nursed them with the tuid me v of i father 
I ovc brinfi forth love and '’Ivo fiuit In 1919 the paces 
of this Joun al were honour id w ilii th- public ition of an 
article on llic Cure of (-npp'cd thildrcn sipncd b> 
Sir Robert Jones and G R Gudieston'’ Ihc c an 
almost Utopian plan for t!u piivcii ion trcatm-nl md 
cdiic ilion of children snflcni 1 from orthopaedic condi 
tions was expounded b\ il e master and (he \ounp 
reformer Now Hurts >ca s ntcr the Wingfield Morns 
Orthopaedic Hospital and he orthopaedic otfaniralion 
of (he Oxford Region stan ' is a listinc monument to 
the nicmois of the genius wlio made Ulop a a rcalitv 
He imparled to this hospital so much of his love that he 
Icav cs behind m n w hat is 1 now n as a W mglicUl 
spirit Hie on!) recemp nvc for which he sought vv is 
Ihc affection of his patients md of those who surrounded 
him and in that he w s imph rewarded We, his 
inlmialc friends have sufTcred an irrcpaiable loss Ins 
patients love a great comforter and England a greil 
social reformer 

SirllMHM CHEMLL NCR CVO IRCS 
One of the few rcmainini p-rsonal linls with Lister is 
brolen bv the death on J imnr) 2 of Sir Leniha! 
Cheallc who had been identilied with Kinns College 
Hospitjl— 1 isitr s 1 oadon hospital for well over half 
a ccnliirv When he wav iirgicd reeivlrar at Nines 
from I'txu onwards he cam- in o close avso'iation with 
I ister who oeeiipicd the chair of surgerv at the Colteec 
until 1S93 ind in f ct Cheallc nssivcd him in th* bsl 
operation that he perform-d 

Gcori c I enllnl Cheallc was horn in ItfS He 
received biv edmation at Merchant Tavlorv School 
and at Rings College and Hospital vjuahfvmg in 
mcdieinc in l'''>' He vnv alrcadv a m'mb-r of the 
Medied So iciv of Kings Co’l-ge in Ihc sevvioa I'lSS-C 
and bv ivs‘> he h’d b%oaae vice president He held a 
number of posts suckcssivciv in his pwa hosp lai vvhrli 
wav then in the neighbourhood of the Strand — d'rnaa 
vtraiO I'f an'tomv house si rg*o 1 louse phvsci n 
surgical rc-istrar an) from 1S92 to 1X9-. demaas.ra 
to of surf al palha 1 o"i Hu appo Pi" -a as ’ssistanl 
Mirge''a at Kiags dated f ora and la I9'''> Ihc 

sear b- eh iircd U c 5 K t ds 1 » was ni dc fu’l 

suicoa at tc ch-r o' s ug „! gi i s’sgc 

Il 're 'v daw o' ll " P'- Wa h- wc-'% o_I to 
Su th \(i 1 wi h h V fo ra- c*" e' S r W a ton Ch'v-- 

i|' e 1 a IS s g'oa w’ o-i I s e' had v- o gv- { ci"a <; a 

'Tit b h o' t' em cc'ivic- a g ra ' om 

kmgs s 'i- S , 1 ' W V ' 'xi 0*a"' v v 3pp-> a 'd 
ia {j (p '-v be vvas p — o-*J 

m s' sp ‘-s csc'c' f' CJ~r —I r -d_! ->- • fp„- 

c ,i'"s 1 - > « s r 'eta -S'*'- o' t'-' B ' I" t*" 
r I s-s - sn o' Isil'-lS te gave t is — v -es to I''p 
K ov.i V sv t’- '-'I o' I g aa rc’ ad™ a! 

-r. ) SS s -- ii- »"d la - has'- '! s'- p S<L -g l' * 
C)’’ -s 1 c - g w" S t " c~i o t" w_t ’■e w. 

K C P H- co~ - :-d 'o •- -V V'3~, o b 2 


<is 


m mN-r o' the Co"su!lalivc Ilaard of th* Koval Nava! 
Medical ServisC an) of th- Admi alt Dst itlTitil 
Committee Sir 1 ea''i 1 Clicall ai o li • v in 1 'im 
pirt in I'lC creation ol i medtv 1 b ans'i of i' c Nav it 

I cigi c 

On hiv rilitrn from nav 1 di ties Ins wo s Sa Km v 
Collc-c Hosgili! vv a rc‘un -d an) m I'O’ h I >' 
sen OT vurgeo i and oa of the Iccturcis o 1 vu i c v He 
retired from llie nlive still m 1'>’0 and w is tpjo itcd 
con iiltiHs Slug on to the 
hopitil ind cniciitns Ice 
tiUer oa thnisil sur, rv 

I I th ri die 1 ! s,.lio il 
Amo ![ ot'i r ippoinl 
mcniv which h- h id he'd 
were those of siirjcon to 
the I lorcOsL Ni, him ilc 
Hospitil md coasiUini 
surgeon to the Hoi[ it d 
for Pii ilvsis tnd I pilcpsv 
the Stirrev Disfxnsaiv md 
the S verm As an I Bur 
ford cottage hovpit ils He 
had v!so hvtvl the vv'het 
of pTesldeal of the See 
tion of Sing rv of the 
Pov ll Sociclv of Mcdi 
cm- Honoms were bestowed on him In lb- llihin 
and ! rcncli Ciovernii ents bv the form 1 he " is 
niae'e an Oflieer of the Cii md < rovv of llalv nd bv 
the latter Chevalier 0 ! the Eeeioii of Ho loiir Ihc 
Anicriem College of Siiri eons nude him an Mo lorurv 
I cllovv in 19^2 In the previous vrur he hid received 
the Wal) cr Prirc from the Rov d Collcg- of Surgeons 
evf En-lard for lus wort, on Ihc palho'og) and thcra 
p-ulics of cancer 

To Ihc end of his life I ivler vv is hiv great hero though 
lus p-rsonit asso-ntioa with him had been limited to 
th- last few vears of I ister s rciga at Kings He spohe 
often of 1 ister V devotion to work and of hiv eoiulcv) 
to all who avvivltd him and vvav fond of (elhnf ho v to 
Lister the op-riimg theatre was a temple of wl ase 
s inctil) he would permit no infrimem-nt O-c o-ci 
smn he rev ill-d was wh-n lister brilhantl) perfo m-d 
an ope alion m 12 «Csonds -nd when th- onlookers 
b ole into a sub't -d cheer he ti tned round and a d 

Gen lem-n rememh— wh-rc vnu arc O - out anJ 
ing cha-ac c ivtic of Lister which Cheat'- «ltosc S' ccev 
fills to emulate wav criipj'o iv aveuraev a-d atlcntioa 
to det 111 He OPS- to d Cf -atle that he co 1 d no rcvall 
eve having riidc an I-3C..U ate st !-- a-al th it th- c 
was no h ag he 1 ad eve said o wri i-a wl c'il-*i''-d 
to ic ra- 
il was 1 IV -< •» latioa wilh I is — nd V a’srm Cl — 
that rav- Ch-„l!- tus sp-vn1 1 - - c‘ mg til o'a-v He 
wav m o' I' n ca e'l 1 o' i-ves i-a ors !_ Iv la 
h V c-iccr h- rc^o-ai/ed the impo-iapce o' cii ting an i 
exaa !- -g 5 - 1 a— o' an afre ed o gia and fa this 
par -u'.r p pm- h* d-v -d th- larg, r-cdone 

o~ I"— av -tvia -d w 'h h s nam- This r-- ‘oJ of 
n c -a ma 1 ,.,-g' -d la pirti-i a- to ca c ro-"a of 

t' - teas ca w-ich s»b -ct la cat the ana aith 
D *l Cu e t— w-o e 3 t-itKaa'i. Tu a,/?- o' trr 
B r*i H- o w 0 c l''- s-c ioa c- al a — ' oa a-'* 
due ses o' I*-- fc ea*' la S - Ja-e- V o- 5 S nr 'c' 
Pc-'-i I i-d t’ - a ca v-gg a ica la C-o ee s 
5 I p— r' — r H- -as o-e c' I-e c- 1 -<t la r ve 
n— •e' r"s o' tCw’-ji 2 - 1 oxta to f,t — j w a aOj-Jv 


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m (fiiffal ptitlKP 111 Irn'i ff ii in lit \t *f t i i 

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ilicnlt ivn in llir oUl At -iilffii llnj n i » -t tlin'i 
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nol only tiiil lo Hlfinl oiil pili-ni tlin t t il nl’O ti i fil 
p i!icnt4 in llicit mm lunnrt S< 'ik* linii. llif'c tttrr I i in 
III lon[ OMKitlion Wiilti llic M'rtilctii Um il lilttinita 
l)t lilt appointment at a' Mini in le-illiclit! l! n tlic 
rico ni/cil tieppini lour lo llir I’ono ii till 1 itrr 
lie t'cc line a titt int ptiwici in and iii I'll'* full pliytlvnn 
mil lecliitcr in cima il iticilaine lo Itic Unitiitll> 

I in illv on lilt telirenienl from the liotpilil in I'H' lie 
\t IV lippoinletl toiittillint pti>vli.i in Al one ima lie iKo 
held tin. potl of oliviciMc plittaiin i| llie Mitcinilt 
llospiiil At an early pciiod in lilt tmer lie het line 
alt itlitd lo llic iniitciii medic i depirimenl of the 
Utiitcrvily lirvl at iiwivi iiit iitd liter it kctiinr lo itic 
I lie Proftvtor C ivti Me la i line inliictled iit Itic 
prohtemv of di ihciet mid coll diot, tied ttilli the lite 
Dr John Ucnnie of tlic nitiird liitlort dtp irliiienl 
cirrtini out tome important rctcuchcs on itie leliolopy 
of this disorder Rennie hid pointed out ih n in i.crliin 
of the leltotican fishes die islands of I itiperlians formed 


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null <■ I I 1 „ (I of I ' " ’ f o- 

I'l'? Il M > !1- M t f’ -M’ ri o' I'f \ ' S 4 

I 4*1 1 1 I'll*? 31 d I * I 411 i' l' 1 t' ' * I “ d I' f* In 

id’ll 1 fio 1 I’>‘l to Mir 'e ti4t a ( r K cif It 

<« - t! 'led i! < o 1 ' 1 JI tilt o' At» dr* ii'" 

fe rr ' op 'ft In ii t’ * diOi > la' i o' D p dt I t i '* n 

O' not* o' III* n 401 ' ino ft t 'i *1 Cir * I' 1 
t t t e f o e p o I Itii 1 l' e I I D dep re n’ *i ih* 

I'mtettilt lO ifei evl npv' l liti l m l"J‘* “ft h'lia tfiSuU 

111 01 e tsh 1 for t 1 ti in\ erih i 't sent hid hcea a 
dcto’id ind hn it 'i o' hit dn i nn’ef 

I'e Inpt lie tt it Ihe IstI tiittiti"' of a peaerilii'a in 
will li it w It piiitih'c fo a mill lo Ctsndu i the iid o’ < 
diilirt of 1 i *net d p u till mer an I at Ihe tan c lim* be 
in oiiltiardinp leivhtr in a medical t'lu'ol and lisdit 
mint of hit former tliulcntt will loot hat with prali 
tilde on all diet learned from him and wdl lemcn I ff hit 
lonriett hit dipmis hit Inin mills and die esamp'c of 
one who londiaicd all hit work on the hdhest citiaal 
slindirdt Me ts Mittited h\ liitvtalow and two tons, 10 
whom imali stmpidis it exiended — A G A 


\V C S wnles Ihe passinp of Dr lliomas I rater 
It not onlt die pattmp of a well hcloted f imiU dixior 

hill die psstini of in cia in i diet il prat lice so fir as die 

Nortli of Scot! ind is concerned Dr f rater s cl unit 
lo Hilda il fame were liul on tert wale and solid 



Jan !3, 1951 


OBITUARY 


BwrmH 

McotcytL Joormal 


97 


foimtiilions He «as a fine example to the medical )oiith 
U the Aberdeen Dispensarj of the combination of the 
bedside manner par cxcclhmc and the shrewd clinical 
obscmtion that stamped him through all his wide prac 
ticc Alwnjs Ihinhing of the patient—carlj or late, far 
or near, poor or rich — if the needs of the ease were 
there so was he Ncser did ans phjsician spend him 
self more unselfishlj for his pjtienis WTienescr an 
operation was performed on anv ot them he made it his 
business to be there so lint he would know exaeth 
what was present and whit was done in each ease In 
this wa> he kept a ser> close watch and ward oscr all 
his cases and was thus ible to assess more fiillj future 
deielopmcnts from past experiences Tor many years 
he enjoyed a fine rcpiitii on as an accoucheur and hts 
help was prized by many eollcigucs as well as by the 
patients It was diflicuii to see how he could stand up 
to so much night work when his daily xistling lists sscre 
so long partii;ulafl\ when one remembers how generous 
he was at any cal! — no hurried in and out for him In 
all his professional dealings he was most correct and 
proper — indeed, cxen fastidious by modern standards — 
but he clung to etiquette and enjosed great kudos for 
that In the earlier days his soicc was heard at medical 
fcsijsc occasions in song ind on more serious occasions 
in speeches that were alwass well prepared and carefully 
delixered in the Asquithian manner He was a soracious 
reader of all sorts of literature and kept himself informed 
on all matters of current medical and general interest 
while spending all day and often part of the night on 
hts daily task his patients He was a student of the art 
and craft of prescribing and therapeutics and elegance 
added to his courtesy at the bedside made him indeed 
the belosed phisieian no trouble was too much — m 
fact he wiped the word trouble out of his dictionary 
Quiet dignity and efficiency inspiring confidence delight 
ful easy friendliness and courtesy abounding combined 
to make him a perfect gentle knight and his memory 
will be long cherished by the laily and by the profession 
he did so much to adorn 

HERBCRT STANLEY FRENCH, C V O , C B E 
DM FRCP 

Dr Herbert French formerly physician to His Majesty s 
Household died m London on January 1 at the age 
of 75 He was at Ihc time of his death consulting 
physician to Guy s Hospitil to Queen Alexandras Mill 
lary Hospital and to the Royal Hospital at Chelsea 

Herbert Stanley French was born in Newcastle 
upon Tyne where his father was a merchant He was 
cdiic iit-d at Dulwich College and Christ Church Oxford, 
10 which he gamed an open scholarship ft was at 
Christ Church that he met the son of Sir James Sawyer, 
a physician of Birmingham svhose daughter Amy he 
married m 1904 After obtaining a first class m the 
National Science School he came to Guys Hospital with 
a university scholarship m 1S98 and there won the 
Bcaney Scholarship the Beancy prize for pathology and 
the Gillson Scholarship of the Society of Apothecaries 
He gradiHtcd BM BCh in 1900 and after holding 
the post of house physician at Guys he held a Rad- 
cliffe Travelling Fellowship from 1902 to 1904 the 
year he proceeded DM In 1906 he was appointci/ 
assistant phvsicnn to Guys Hospital and m 1917 full 
physician He v\as admitted FRCP in 1907 and was 
Goulstoman Lecturer m 1908 choosing as his subject 

The Medical Diseases ot Pregnant Women For 


many years he was physician to HM Household 
During the first world war he served as honorary 
lieutenant colonel in the R A M C and was appointed 
consultant to a large military hospital at Aldershot He 
also became consultant physician to Ihe Queen Alex 
andra Military Hospital Millbank the Royal Hospital 
Chelsea the Radium Institute, the Enfield Hospital and 
the Surrey Dispensary He was made a C BE in 1919 
and a C V O in 1930 In 1928 he was president of the 
Harxcian Society Early m hts career he examined m 
medicine for the Society of Apothecaries ind later for 
the University of Oxford and the Royal College of 
Physicians He was the author of many articles in 
journals and textbooks but in (his held he achieved 
most fame as editor of An JiuUx of Dtfjcrcnnal Diag 
nous of Mtnn Sxmplomt which first appeared in 1912 
He retired from professional life in 1929 when still in 
active middle age and devoted himself to his property 
in Surrey where he turned with whole hearted cnihu 
siasm to fruit farming and cider and chutney making 
His first wife died m 1946, and in 1948 he married Nora 
widow of Edward McDonald He leaves a widow, son 
and daughter 

A H D writes Trench appeared never to hive any 
doubts about his decisions or the goal for which he was 
making His determination to succeed was evident in 
his student days, and as he passed through the successive 
phases of house physician and registrar to assistant 
physician his quite extnordmary power of intense 
industry became more and more apparent As 'a house 
physician he started collecting notes, sketches and photo 
graphs of eases of interest thus providing the core of 
the book which was later to make him famous Soon 
after election to the staff at Guy s he developed pulmo 
nary tuberculosis and went for some months to Corn 
wall where he devoted his time to sailing and hshtng 
Within a few months he was back at work, clearlv 
recovering m spite of the most exiguous treatment as 
judged by modern standards He delighted m later 
years to demonstrate his health and strength in spile 
as he said, of 16 positive sputa’ 

He was a most impressive teacher partly because of 
hts love of the dramatic and of simile pirtly because 
of the emphasis he would lay on the practical side of 
therapeutics He was just as ready to teach the best 
way to insert a bed pan as he was to discuss the latest 
development of Ihc focal sepsis theory His post 
mortem demonstrations and reports were a model of 
lucidity and an example to those who followed him 
His clinical lectures always secured him a picked 
theatre where he would without apparent effort speak 
and illustrate on the blackboard for an hour without 
notes and without hesitation He prided himself on 
a teutonic mcticulousness which made it possible for 
him to edit An liidix of Difjtnniiii! Diagnosis of 
Main Symptoms The index alone took a year to com 
plctc and entailed the making of over half a million 
entries Most of this work was done when travelling 
in his car to consultations for which he w I's in ever- 
growing demand His other most important contribu 
tion to medicine was a description of influcrfza as it 
appeared m the 1918 pandemic During these years he 
continued to extend the scope of his clinical experience 
while fostering an ever increasing consulting practice, 
which by the end of the war was probibly one of the 
largest in the kingdom Hts health was now robust and 
he was able to enjoy a ful! social life m addition to 
his professional activities By 1920 the strain on liis 




98 Jan }3, 1951 


OBITUARY 


BulTIiH 

Aiedical Journal 


capacity for work had reached fabulous proportions, and 
he had come to the stage of success when not only doc- 
tors but also laymen would ask for his help He was 
a strict observer of etiquette in relation to professional 
work and never allowed the patient to consult him with- 
out the knowledge 'of the general practitioner 
' With 1 characteristically dramatic gesture he retired 
at the age of 55, sold his house and everything in it, 
even to his stethoscope, and retreated to Newdigatc in 
Surrey Here he was able to enjoy, the delights of 
country life and holidays on his jacht He had taken 
his master s certificate a'nd grasped with his usual clanty 
of mind the intricacies of navigation His health and 
strength seemed imperishable ' The death of his wife 
a few years ago was a great blow to him, but he faced 
this with the same indomitable courage which he showed 
in his final illness His happiness was restored when he 
married again some two years ago, but a painful and 
fatal illness struck him last autumn, and he ended his 
days in the hospital he loved and served so well 

GEORGE C CATHCART, M D 
Dr George Clark Cathcart,~who died in a nursing-home 
at Broadstairs on January 4 in his 9Ist year, practised 
as an ear nose and throat specialist for many years 
in Upper Wimpole Street and m his day had one of the 
best consulting practices in the West End of London 
Cathcart belonged to an old Edinburgh family, his 
elder brother Charles being a well known teacher of 
surgery "at Edinburgh, and he went to school at Edin- 
burgh Academy and Loretto He graduated M A at 
Edinburgh in 1883, and thereafter went to Australia and 
back in a sailing ship and was a pupil at Naples of 
Scarfali, one of the, last teachers of the old Italian bel 
ennta in order to cure, a stammer He returned to 
Edinburgh to study medicine, graduating M B , C M 
in 1891 and proceeding to M D in 1908 He came to 
London as a resident at the Children s Hospital, Great 
Ormond Street, as did many Edinburgh graduates^ of 
those days, and then became resident house-surgeon at 
the old London Throat Hospital (later amalgamated 
with the Throat Hospital, Golden Square), to which 
he was later appointed honorary surgeon After the 
amalgamation he became consulting surgeon to the 
Throat Hospital Golden Square, and he was also con 
suiting laryngologist to Mount Vernon Hospital, ir^ the 
days when it was still a hospital for tuberculosis 
During and after the first world war he was a member 
of the Special Aural Board of the Ministry of Pensions 
In his earlier days Dr Cathcart was greatly interested 
in problems of the voice, and at that time his contribu- 
tions to medical literature were mainly on such subjects 
,as voice production, stammering and tonsillectomy It 
was directly because of this interest that in 1894 be 
founded the famous Promenade Concerts at the Queen s 
Hall London He insisted that in order to prevent 
vocal strain the orchestral instruments should be tuned 
to French pitch and not to the higher concert pitch, as 
was then 'usual , and he also insisted that his young 
friend and discovery, Henry Wood, should be the 
conductor of the series of concerts Then a young 
bachelor of independent means, Cathcart was quite con- 
tent in order to prove his thesis to lose several thousand 
pounds in starting the concerts, and when they began 
to pay their way he gave place to others In his later 
days he became more and more interested in deafness 
and Its prevention He revised and largely re wrote his 


friend Hunter Tods Diseases of the Ear m 1926, and 
in 1931 published a small book. The Treatment of 
Chronic Deafness which went into a second edition 
Not infrequently the victim of his own kind heart he 
was also ever sympathetic towards the unorthodox in 
medicine— homoeopathy, osteopathy, the electropbonotde 
method of Zund Burguet He had always a current 
favourite among such methods and their practitioners 
He was an ardent freemason, having been a Past Master 
of the University of Edinburgh Lodge and a member of 
Grand Lodge 

Dr Cathcart never married, but he had many nieces 
and other relatives to whom he was devoted, and there 
can have been few men more beloved by 'more friends 
in every walk of life — R S S 


Dr Alma Percv Ford who from 1919 devoted his life 
to the care of patients suffering from tubSrcuIosis in the 
county of Hertford died suddenly on December 18 19^0 at 
tha age of 60 Born at Spalding Lincolnshire he was the 
son of Alderman A Ford J P After leaving the Mercers 
School he sUwiied medicine at the London Hospital where 
he qualified in 1914 On the outbreak of the first w'orld war 
he volunteered for service in the R A M C and was sent to 
France in August 1914 where he served until he was- 
demobilized early in 1919 He look the D P H in 1920 and 
after a short period as assistant school medical officer in 
Huddersfield he was appointed tuberculosis officer m Herl 
fordshire and also deputy county medical officer He 
became the driving force behind the great development of 
the tuberculosis service in the count) and his work was 
recognized in his appointmeni as one of the two representa 
tives 'of the British Medical Association on the Joint 
Tuberculosis Council At the time of his death he was 
honorary treasurer of the Council a position which he had 
held for many years At the inception of the National 
Health Service Ford was chief clinical tuberculosis officer m 
Hertfordshire and medical superintendent of Ware Park 
Sanatorium After July 1948 he became a consultant chest 
physician and physician superintendent of Ware Park Sana 
torium Always a keen member of the British Medical 
Association he was honorary secretary of the East Herts 
Division from 1931 until 1938 and was chairman of the 
Division from 1939 until 1944 guiding the members through 
the difficult war years with oulstandinc clarity of jiidgmenl 
and tact None of his friends and colleagues in the Join! 
Tuberculosis Council and British Medical Association will 
forget his forthright personahtj radiating from his powerful 
well built figure His interests were wide — at one time he 
was captain of the London Hospital association football 
team he held a lifelong passion for cricket he was a keen 
golfer holding the Ledward Cup for several years and he 
was an active supporter of the Amateur Dramatic Society of 
Hertford Ford contributed a number of papers lo medical 
journals on various aspects of the treatment of tuberculosis 
and was joint author with the late Dr Hyslop Thomson of - 
Tuberculosis of the Lungs published in 1927 His loss will 
be widely felt not only by his med cal and nursing colleagues, 
and his many friends but by innumerable patients all over 
the country who have known hts sympathy and djnamic 
energy In 1915 he married Lilla Robeson who with their 
two daughters survives him — C P C 


The Services 


The London Gazette has announced the following awards 
Bar to Air Force Cross— Wing Commander H P K Smiin. 

^ Air Force Cross — Squadron Leader J S Homtt RAF 



Jan 13, 1951 


UNIVERSITIES AND COLLEGES 


Bkttish 

^^£PlCJU. JOLWta 


99 


Universities and Colleges 


UNIN'ERSITY OF OXFORD 

In Convocation on January 16 it will be proposed to confer the 
honorary degree of DCL on the Rl Hon Sir Godfrey Marun 
Huegms PC CH KCMG FRCS Pnmc Minister of 
Southern Rhodesia 

UNIVCRSin OF SHEFFIELD 
The Council of (he University has decided that the new Hall of 
Residence for Men which is being erccied m OaUioIme Road 
shall be mmed Stephenson HaJi m honour of members of that 
family who ha\e served the University and its forerunners in 
successive generations 

Dr D E Price has been appointed Honorary Lecturer in 
Pathology 


EPIDEMIOLOGICAL NOTES 

Smallpox at Brigfatoa 

to noon on January 9 there were 17 patients bebeved 
to be suffenn^j from smallpox in Brighton county borough 
or tn the immediate vicinity of these cases Two have died 
and the diagnosis in three was stilJ in doubt During the 
previous week the infection had been confined to the two 
oncinal foci — the laundry to which the clothing of the 
initial case an R A F officer was «:em and the hospital, 
in which the second case was not diagnosed for 10 days 
Among the laundry employees there have been six cases 
Two of these worked at a receiving branch and the 
remainder in the mam estibhshment The laundry has 
now stopped work The hospital is in quarantine and 
members of its staff admitted to the smallpox hospital 
consist of five nurses and one domestic AH these penons 
were employed on the ward to which the second case was 
ndmitted and nursed m a cubicle '' 

The vaccinal state of the nursing and domestic staff at 
the infectious disease hospital was unsatisfactory 27 out 
of 113 never having been vaccinated On investigatioo 
among nurses and domestics attached to the ward con 
cerned it was found that seven were unvacemated Of 
these three had very httle contact with the patient and 
did not get the disease All the remainder had intimate 
contact and one died and three are in a serious condi 
tion The other two nurses now in the smallpox hospital 
have a good vaccinal history and in their cases there is 
still some doubt about the diagnosis 

Pohomjelitis 

Poliomyelitis notifications in the concluding week of 1950 
were paralytic 36 (38) non paralyltc 17 (15) total 53 
(53) The figures for the previous week are in parentheses 
The tcfial uncorrected notifications for 1950 are 8 696 com 
pared with 9 195 in 1947 2 379 m 1948 and 6 857 in 1949 
There were no notifications in the week under review 
from 35 couniv areas and in the remainder notifications 
were more or less evenly distributed, no county notifying 
more than four 

The incidence of pohomyelilis in 1950 after correction of 
notifications is hardly likely to be much less than that in 
1947 when it was 4{ times greater than in any previous 
year since compulsory notifications began m 1912 

Influenza 

The statistics given below for England and Wales and 
the Great Towns do not indicate any senous epidemic of 
influenza up to the end of the year Any increases m 
pneumonia casts and deaths and influenza deaths are not 
much more than norma! for the time of year A mild 
form of influenza but of a very infectious type, has been 
epidemic in the north east of the country, including 


Newcastle upon Tyne and elsewhere in parts of Lanca- 
shire including Liverpool and in Birkenhead (Cheshire) 
Bui in these districts the epidemic has probably passed 
its peak Serological investigations have shown that the 
epidemic in Tyneside is due to virus A it may be identical 
with that m the Scandinavian outbreaks — virus A pome 
The results of further laboratory investigations are awaited 
There is at present no evidence of spread of the epidemic 
lo the Midlands and South But in many areas there arc 
local outbreaks of a mild disease with symptoms not unlike 
those of influenza they have not yet been shown to be 
due to an influenza virus 

There is serological evidence that in Sardinia cases of 
influenza have been due to virus B 
The following cases of and deaths from pneumonia and 
influenza have been reported in the Great Towns 


1 

28/10 

*nt 

11/11 

!i8/11 

25/11 

2/12 

9/12 

16 / 12 I 

'23/12 

! 30/12 

Poeumoflia i 


\ 





1 .147 


i 


Cams I 

236 

1 281 

261 

313 

302 

t 282 


! 374 

' 364 

502 

Deatbs { 

|4I 

198 j 

177 

lliS 

207 

1 198 

! '‘36 

: 21>9 

351 

383 












Destbs i 

17 

19 j 

20 

16 j 

24 

28 

34 

33 

54 j 

102 


Totals from the first week of the year in the Great Towns 
compared with the preceding two years are as follows 



1948 

1949 

1950 

Fceomooia 



16 452 


17416 

19 043 

Deaths 

10 337 

11 786 

10 461 

Iztflumra 



I S59 

Deaths , 

608 

3 090 


The following Tabic shows notifications of pneumonia—' 
pnmary and influenzal — in England and Wales 



28/10 


n/11 

18/11 

25/11 

2/12 

9/12 i 

I6/I2'23/I2; 

30/13 

PneufDcrala 

43S 

TsT' 

465 

558 

490 1 

497 j 

573 

684 i 

647 1 

962 

Coirespondjng 

week 1949 

303 

4I9 

1 

534 

667 

710 j 

7.5 j 

734 j 

676 j 

1 

634 j 

842 


The following cities and large towns had the largest 
numbers of pneumonia notifications in the week ending 
December 30 1950 London 64 Birmingham 38 Sunder 
land 32 Sheffield 24 Manchester 23, Liverpool IS Gates 
head J5 Salford J4 Newtaslle 14 

The following weekly claims have been made on the 
Ministry of National Insurance Week ending October 28 
1950 127245 November 4 144 446 November 11 148 497 
November 18 147 415 November 25 145 783 December 2 
1420n December 9 141 403 December 16 128842 
December 23 87 277 (four days only) 

Regavmal totals of influenza deaths in the Great Towns in 
the week ending December 30 1950 were Greater London 
(included in London and South east) 22 Northern 34 East 
and West Ridings 4 North weslern 30 North Midland I, 
Midland 6 Eastern I London and South east 24, Soulheni 
2, South western 3, Wales 1 , total 106 

Infectious Diseases 

A large fall occurred in the number of notifications of 
most infectious diseases in England and Wales during the 
week ending December 23 1950 The falls included 

whooping-cough 768 scarlet fever 242 dysentery 190, and 
acute poliomyelitis 54 The only large exception to ‘the 
general decline was a rise of 105 in the notifications of 
measles The notifications of acute poliomyelitis were 7 
fewer than in the corresponding week of 1947 and 18 fewer 
than tn J949 One third of the cases of acute poliomyelitis 
were notified m London and the adjacent counties during 
the week 



100 Jan. 13, 1951 


EPIDEMIOLOGY SECTION 


Bwttish , 
Medical Journal 


During the 5Ist md 52nd weeTs of 1950 54 and 102 
deaths were attributed to influenza in the Great Towns of 
England and Wales These are about twice the numbers 
registered dining the corresponding weeks of recent years 
Notifications of inlluenza usually rise to a maximum towards 
the end of the first quarter, and it is possible that the 
present outbreak will be larger than those that have occurred 
in the last few years The disease is now prevalent chiefly 
in the northern cities 

^ rijsenterj 

The notifications of dysentery were 190 fewer than in 
the preceding week, but with this exception they were the 
highest ever recorded The chief features of the returns 
during the week were large falls in Leicestershire 138 and 
Lancashire 8(9 and rises in Staffordshire 49 and Middlesex 29 
The largest returns were Lancashire 173 (Southport CB 
53 Oldham C B 25, Salford C B 20, Manchester C B 20) 
Leicestershire 101 (Leicester CB 89), Yorkshire West 
Riding 136 (Earby U D 58 Bradford CB 19 Sheffield 
C B 14) Staffordshire 74 (Stoke on Trent C B 44 Stafford 
M B 11 Cheadic R D 10) Middlesex 69 (Edmonton M B 
54) london 60 (Poplar 13 Islington 12) Shropshire 48 
(Shrewsbury M B 26 Whitchurch U D 12) Warwickshire 
34 (Birmincham CB 30) Cheshire 29 (Wirral R D 8) 
Essex 26 (Romford M B 15 West Ham C B 9) Glamorgan 
shire 23 Monmouthshire 23 (Newport C B 9) Suney 2_ 
(Esher U D 9) Yorkshire North Riding 17 (M^dles 

brough CB 17) Northumberland 16 (Glendale RD 9) 

Devonshire 16 (Exeter CB 10) Durharn 15, Norfolk 15 
(Mitford and Launditch R D 15) Kent 13 Somersetshire 
12 Sussex 11 Soulh'impton 10 Northamptonshire 10^ 
(Kettering MB 9), Gloucestershire 10 

^ Week Ending December 30 

The notifications of infectious diseases in England and 
Wales during the week included scarlet fever 1 02 , 
whooping cough 3 690 diphtheria 41 measles ^^8, acute 
pneumonia 962 acute poliomyelitis 53 
tvohoid fever 6 Four cases of smallpox mending nv^o 
iSorVed cases were notified In the Gregt Towns the 
number of deaths from influenza was 102 ^ 

Quarterly Returns for Scotland 
The birth rate during the third quarter of 1950 was 17 3 

gf rl .M9« ,S',rbVi.w ih, 

^/corresponding disfaLf D 

mfluenza 9 to mMStes and 9 to whooping cough, 38 deaths 
tt^etrtegistered from acute poliomyelitis 

Industrial Accidents and Diseases 
According to the M.nntry of Lcb^^r the 

1950) the number of ^^^/^“'’'^‘’/.dents m the course of 
United Kingdom ,950 was 151 compared 

their employment in N°y "1 ^er 1950 and 123 (revised 
with 112 (revised fieure) m Ortober 

i« » 

deaths of 11 tsaote" o'Ofo I diseases were reported 

i.’SirhTr'-lof 

:«k%K.rop?g£S htr , 0,1 P, and 

chrome ulceration 10 total 


' - ' No 51 

INFECTIOUS DISEASES AND VITAL STATISTICS 

We pnnt below a Summary of Infectious Diseases and Vital 
Statistics in the British Isles during the week ended December 23 
Figures of Principal Nouliable Uiseases for the week and those for the corre 

Wales (London included) (b) 
(d)Eire (e) Northern Ireland 
1 recorded under e ich h/eciious 
England and Wales (including 
London) (b) London (administrative county) (c)The 16 principal towns in 
Scotland (d) The 13 pnncipal towns Jn Eire (e) The 10 principal towns m 
Northern Ireland . . 

A dash — denotes no cases a blank space denotes disease not notifiable or 
no return avathble 


Disease 

1950 |l 

949 (CorrespondmgWeck 

(a) 

(W| 

(0 1 (d) 1 

(e) 

(a) 

(b) 

(c) 

(d) 

(e) 

Meningococcal mfee 
tion 

Deaths 

3! 

3 

1 

18 

1 

I 

- 

/ 

28 



10 

i 

- 

I 

Diphtheria 

Deaths 

•46 

2 

13 

5 

I 

81 

15 

25 

1 

3 

Dysentery 

Deaths 

1 024 

60 

148 


4 

221 

16 

67 

! 

4 

Encephalitis acute 
Deaths 

6 

1 

— 

— 

— 

1 

\ 

- 


— 

— 

ErvsipeHs 

Deaths 



28 

"5 

4 


- 

28 

6 

3 

Infective enteritis or 
diarrhoea under 

2 vears 

Deaths 

22 

1 

7 

9 

it 

27 

1 

1 

27 

4 

2 

Measles* 

Dcaths+ 

14 328 

1556 

1 

197 

120 

2 

79 

I 684 

32 

A 

23 

47 

107 

I 

Ophthalmia neona 
torum 

Deaths 

37 

1 

9 

! 

1 

35 

1 

2 

7 

— 

i 

Paratyphoid foer 
Deaths 

3 

— 

H 


J 

5 


2(B) 


Pneumonia influen 
zol 

Deaths (from in 
fluenra)^ 

Pneumonia primary 
Deaths 

Poliomyelitis acute 
Deaths! j 

Puerperal fever 
Deaths 

Puerperal pyrcxiall 
Deaths 

^7 

54 

42 

4 

IZ 

5 


2 

1 

634' 

27 

29 

5 

7 

2 

4' 

2 

7 

2 

350 

69 

301 


•J 

296 

44 

296 

22 

iJ! 

9 

53 

3 

6 

1 

4 

3 

— 1 

81 

5 

8 

2 

' 2 




1 




— 1 

3 


1 

74 

10 

5 


1 

72 

6 

7 

1 

Kelap mg fever 
Deaths 

Scarlet fever 

Deathst 

- 

— 



— 

— 

— 




1 106 

87 

176 

57 

42 

2416 

142 

221 

81 

176 

Smallpox 

Deaths 

Typhoid fever 

Deaths 

Typhus fever 

Deaths 

Whoopinc-cough 

- 

— 

— 


— 

— 

— 

~ 

_£ 

- 

5 

1 


" 2 


1 

i 

: — 

— 

1 

1 1 

- 

- 

- 

— 

— 

— 

— 

— 


- 

3 735 
13 

; 360 
; 2 

1 604 

1 77 

' 3C 

9361 39 

63 

a : 

1 

> 44 

Deaths (0-1 year) 

29S 

> y. 

1 a : 

1 ' 

J u 

) 33: 

1 43 

4”= 

41 

i 12 

Deaths (excluding 
stillbirths) 
Annual death ratS 
(per 1 000 per 
sons living) 

6 971 

1 108! 

; 791 

15^ 

1 I8f 

) 

J I5-: 

1 57L 

i 

1 863 

701 

14 I 

25; 

151 

S 149 

i 

Live births 

Annual rate per 
1 000 persons 
living 

Stillbirths 

Rate per 1 OOO 
total births (in 

6411 

1 99! 

! 805 

16: 

) 347 

1 

r 20( 

; 6 565 

) 1015 

877 

17 f 

321 

20: 

5 204 

2 

) 

t 21 

J 21 

2‘ 

[ 


17: 

7 23 

1 24 

O' 




Mca^le^ i** n )l notmaoie m olououu ou 
"'TS-' frorJn^aslc. and ^aric. fever for England and Wal« London 
^iTclnSVv pnraw'^^rm'VS? eS Wales London (adm.mstraUve 

“""nfberordlsrlifrrcm pol.omyelim and Pol™|“"'- 
Enstand and 
II Includes 
ii Primary 



Jan 13 1951 


MEDICALxNEWS 


Bfunsu 

MEDICAI. JOUKNAI. 


101 


Medical News 


New Year Honours 

In the New Year Honours a Knighthood was conferred on 
Mr Percy Barter C B Chairman of the Board of Control 
and on Mr Thomas Dalling M R C V S Chief Veterinary 
Officer Ministry of Agriculture and Fisheries Mr Barter 
has been Chairman of the Board of Control and Under Sec 
relary Ministry of Health since 1945 having been previously 
secretary of the Board from 1930 to 1939 and Principal 
Assistant Secretary Ministry of Health from 1940 to 1945 
Mr Dalling has undertaken important work on canine 
distemper and on problems connected with immunization 
against other animal diseases including tuberculosis 

Amended National Formulary 

The second amendment list dated 1950 has just been 
issued The mam change is the introduction of dexampheta 
mine (the official name for the proprietaries dexednne 
and dexamed ) as Tabellae Dexamphetaminae Sulphatis 
* Six tablets each containing 5 mg to be dispensed unless 
otherwise directed 

Profits from Streptomycin 

Dr Albert Schatz of New York who was a student of 
Dr Selman Waksman when streptomycin was discovered 
recently brought a successful court action against Dr Waks 
man for recognition as co discoverer and a share in the 
royalties He will receive 3% of royalties accruing after 
October 1 1950 and S150 000 dollars (about £43 500) for 
relinquishing foreign rights in the antibiotic The net 
royalties up to this date are estimated at some S2 360 000 
(about £843 000) but Dr Waksman has received 
only about S350 000 (£125 000) The remainder went to 
the Rutgers Research and Endowment Foundation to which 
Dr Waksman made over part of the rights It is not 
directly connected with Rutgers University where the drug 
was discovered Under the new settlement 7% of the net 
royalties will be divided among 13 other graduate students 
of Rutgers and cash bonuses will be paid to 12 assistants 
The Foundation will still continue to receive 80% of the 
streptomycin royalties and Dr Waksman will receive 10% 
Originally Dr Waksman received 20% but when the 
royalties began to mount up to big figures he asked the 
Foundation to Cut his share by half 

New Journal of Therapeutic^ 

The publication- of a new monthly journal Antibiotic 
ami Chemotherapy is announced by the Washington Insti 
tiite of Medicine Early contributions will include reviews 
of the present status of antibiotic )herapy ACTH corti 
sone the chemotherapy of tuberculosis and details of newer 
antibiotics The journal is published from 1708 Massachu 
setts Avenue Washington at a subscnption of SIO per 
annum 

In Brief ' 

Dr Edith Summerskill Minister of National Insurance is 
visiting Egypt January J4-21 to study the development of 
social services there ^ 

Wills 

Dr Herbert Morley Fletcher formerly consulting physi 
Clan St Bartholomew s Hospital London left £21 196, inclu ^ 
ding £100 to the Royal Medical Benevolent Fund Dr 
Arthur StanbUry Cobbledick formerly of Trevone near 
Padstow Cornwall left £11 738 including £100 to the Royal 
Eye Hospital St George s Circus London S E Dr Doug 
las Craig of Cornngham Essex left £27 000 Dr Robert 
Percy McDonnell late chief medical adviser Department of 
Local Government and Public Health Ireland left £11 838 
He left £50 for Masses and £25 each to the Dubhn branches 
of the N S P C C and S P &A 


COMING EVENTS 

Royal Institute of Public Health and Hygiene 
Whole time and part time courses for the Certificate and 
Diploma m Public Health and for the Diploma in Industrial 
Health begin on various dates on and after January 26 Full 
details may be obtained from the secretary 28 Portland 
Place London W 1 

Radiology Course ' 

The Faculty of Radiologists will hold a postgraduate 
week end course on February 17 and 18 Lecture demon 
stralions will be given on (I) diagnostic radiology and 
(2) radiotherapy Full particulars may be obtained from 
the honorary secretary Faculty of Radiologists 45 Lincoln s 
Inn Fields London W C 2 

> 

Social and Preventive Paediatncs 

A course of 10 lectures for postgraduates on social and 
preventive paediatrics began at the Hospital for Sick 
Children Great Ormond Street London W C on 
January 8 when Sir James Spence spoke on The 
Influence of Environment on Disease in Childhood 
The remaining lectures will be delivered weekly on 
Mondays at 5 p m until March 12 and ^details will be 
published in the Societies and Lectures column of the 
Journal The fee for the course is £3 3s (single lectures 
7s 6d) and applications for tickets of admission accom 
panied by a remittance should be sent to the secretary of 
the Institute of Child Health at the hospital 
' \ 

Psychopathology of Cerebral Diseases 

Professor Manfred Bleuler of the University of Zurich 
will deliver a lecture on The Psychopathology of Cerebral 
Diseases at the Institute of Neurology National Hospital 
Queen Square London WC on Tuesday February J 3 
at 5 p m ' 

Polish Doctors in Great Bntam 
An Assembly of Polish Doctors in Great Britain will 
take place at B M A House Tavistock Square London 
WC on Friday and Saturday January 39 and 20 On 
January 19 the proceedings which begin at 11 am include 
an address by Sir Alexander Fleming F R S on The 
Search for Antibiotics and in the afternoon a paper by 
Dr L Surzynski on Social and Professional Problems 
Facing Emigr6 Polish Doctors Full particulars may be 
obtained from the chairman of the Polish Medical 
Association 14 Collmgham Gardens London SW5 


SOCIETIES AND LECTURES 
Monday 

Durham University — At Royal Victoria Infirmary Newcastle 
upon Tyne January 15 5 15 pm Experiments in Learning 
Rutherford Morison Lecture by Professor J Z Young F R S 
Hunterian Society — At the Mansion House London EC 
January 15 8 30 pm The Atienographic Approach to the 
Study of Arteritis by Professor F Orban (Li^ge) 
©Institute of Child Health Hospital for Sick Children Great 
Ormond Street London WC — January 15 5 pm The 
Economics of Child Health by Dr J D Kershaw 
Institute of Urology— At St Pauls Hospital Endell Street 
London W C January 15 10 a m Calculous Disease of 
Bladder and Urethra by Mr F J F Barrington llJOnm 
Marion 5 Disease and Dixerticuhim of Bladder by Mr H ^ 
Vernon 2pm Congeniial Defects of Bladder and Urethra 
by Mr J E Semple 3 30 p m demonstration Endoscopic 
Instruments b> Mr A R C Higham 5pm Administration 
of Sulphonamides and Antibiotics by Dr A H Harkn^ 
Roval Eye Hospital St Georges Circus Southwark London 
SE — ^January 15 4 pm, Optics (Rexistoii) by Mr H N 
Reed 

ORoval Eye Hospital St George s Circus Southwark London 
SE — January 15 530 pm Anatomy of the Eye and Orbit 
by Professor T Nicol 

Scientific Film Association Medical Comviittee — At Royal 
Society of Medicine 1 Wimpole Street London W January 
•55pm Films on Child Health will be shown and discussed 



102 Jan 13. 1951 


MEDICAL NEWS 


Bwnsn 

MZDtcJa. JovKNKt. 


Tuesday 

Mcdical Federation —At London School 
w Medicine Keppel Street London, 

' m *®i 5 30 p m Observations on the Circulation 

in the Human Limbs by Professhr H Barcrott 

Society Burlington House, 
Piccadilly London W January 16 5 30 pm Congenital 
Malformations by Dr C O Carter , * 

•INSTITUTF or DcrMiTOLOGY Lisle Street Leicester Square 
London WC— ^nnuary 16 5 p m Zdonoses (ParastUc 
Infemoits) by Dr MS Thomson 
Institute of Urology —(D Ai St Paul s Hospital EndclJ Street 
London WC January 16 lOam Jniunes Benii^n Growths 
Bodies tn the Bladder by Mr Harland Rees. 

1 1 30 T m New Growths of the Bladder (li by Mr J G 
^ndrey 2 pm New Growths of the Bladder f2l by 
J ^ St Peter s Hospital Hennetia Sirccl 

London wC 3 30 pm w-ird round by Mr Harland Rees 
5 pm H Ufology of Bladder Growths by Dr C E Dukes 

R(^al Evp Hospital Si Georges Circus Southwark London 
SL-~JnnuTry 16 5 pm Sursery of the (ns by Mr T M 
Tyrrell 

Society for the Study of Addictiov— At Medical Society of 
London 11 Clnndos Street Cavendish Square London W, 
January 16 4 pm Chnicol Experiences tn the Treatment of ^ 
Alcoholism by Dr J A Hobson A discussion svill follow 


England Linc^n s Inn Fields London WC, 215 nm 
sjnnposmm The Reticuloses speakers Drs if M Levitt 
Geoffrey Boden, (3) At Dorchester Hotel 
London W 7 30 p m dinner ' 

British Institute of Radiology 32 Welbeck Street, London 
W January_19 5 pm meeting of medical members 


Wednesday 

Harvehn Society OF London 11 Chandos Street London W — 
January 17, 7 45 pm annual general meeting 8 45 pm 
^ The Continuing Problem of Phthisis presidential address by 
Dr R R Tnil 

•Institute or Dermatoloov Lisle Street Leicester Square 
Londop WC — January 17 5 pm, * Medical Mycology 
lecture demonstration by Dr R W Riddell 

Institute or Urology —At St Pauls Hospital Endell Street, 
London WC January 17 1130 am A Survey of the 
Methods of Treatment in Benign Prosfatic Enlargement by 
Mr A C Morson 2 pm Hydronephrosis by Mr H P 
Winsbury White 3 30 p m ' X rays by Mr H 1C Vernon 
5 pm Museum Demonstration by Mr D I Williams 

Royal Eye Hoseital St George s Circus Southwark London 
SE — January 17 5 30 pm, Retinoblastoma by Mr R P 
Crick 

RoyVl Micboscopical Society Tavistock House South Tavistock 
Square London W C — January 17 5 30 p m annual general 
meeting 6pm The Virus and the Cell presidential address 
by Dr G M Findlay 

Thursday 

British Institute of Radiology 32 Welbeck Street London, 
W — January 18 8 15 pm joint meeting with Radio 

logical Section Royal Society of Medicine and Faculty of 
Radiologists Symposium The Reticuloses speakers 
Drs W St C Symmers R Bodley Scott, and F Campbell 
Golding I 

British Postgraduate Medical Federation — At London School 
of Hygiene and Tropical Medicine Keppel Street London 
WC January 18 5 30 pm ' Cerebral Responses to Peripheral 
Stimiih m Man by Dr G D Dawson 

Edinburgh Clinical Club — At B M A Rooms 7 Drumsheugh 
Gardens Edinburgh January 18 8pm Sinusitis and Nasal 
Catarrh by Dr J F Birrell 

Institute of Uhoiogy — ^Al St Pauls Hospital Endell Street 
London W C January 18 10 am Retropubic Operations 
on the Prostate by Mr A W Badenoch 1 1 30 a m Endo 
scopic Operations on the Prostate by Mr A W Badenoch 
2 pm Transiesical Operations on the Prostate by 
Mr A R C Higham 3 30 p m ward round by Mr D I 
Williams 5pm Radiotherapy and Radium by Dr S B 
Osborn ^ , 

Liverpool Medical Institution 114 Mount Pleasant Liverpool 
— January 18 8 pm Inguinal Hernia by Mr John A 

RoyaL Eye Hospital St Georges Circus Southwark London * 
SE — January 18 5 pm Ocular Palsy by Dr S Nevm 

Royal Socifty of Tropical Medicine ano Hyoienp — At 26 
Portland Place London W Januaiy 18 7 30 pm Foreami 
(ponds Rente Ehsaheth pour I Assistance Medicate aitx 
Indigenes) in the Belgian Congo by Professor- Ren6 Mouchet 

St Gforge s Hospital Medical School Hvde Park Comer 
London SW— January IS 4 30 pm lecture-demonstration 

UNTORsm °^roLLErE (Phvsiolooy TheatbeI Gower Street * 
London WC— January 18 5 15 pm Phuicocftem/col 

Properf/a ond Pharmacological Acinity of Drugs by Mr r 
Bergel, Ph D D Sc 

Friday 

British Institute of Kxdioiogy —January 19 lomt meeting 
with R^dlo1oGlc^l Section Royal Soacty of Medicine and 
Faculty of R'idiofo'’jsts continued ft) At Rovai Soaety of 
Medicine ! Wimoole Street London W 10 30 am sym 
Tjosium The Reficidoses speaker? Dr Bnan Russell 
Profes<?or R McV^^irter Drs D G Galfon J D N Nabarro 
and John Boland (2) At Royal College of Surgeons of 


* wr^''i‘-°“^ 3 -At St Pauls Hospital Endell Street 

London W C January 19 10 a m Malignant Disease of the 
uTrr ,L I F"B“ssQn 1130 am Stricture of 

I Semple 2pm, Infertihly of tlie 
Male by Mr A R C Higham 3 30 p m Museum Demon 
stranon by Mr J E Semple 

London Association or the Medical Women s’ Federation — 
At RoyabFree Hospital School of Medicine 8 Hunler Sircet 
Brunswick Square London WC January 19 8 30 pm 
iReeenl Deielopmems In Cardiac Surgery at Guys Hospital 
by Mr Lawrence Whytehead 

St Georges Circus Southwark London 
S E —January 19 5 30 p m Phy'siology of the Eye 
Royal Medical Society 7 Melbourne Place Edinburgh — 
January 19 8 p m The Curious Effects of Carbon Monoxide 
Poisoning address by Dr J K Slater 

Saturday , 

Nutrition Society — At London School of Hvgiene and Tropical 
Medicine Keppel Street Gower Street London W C January 
20 ip30 am Tbe Comporame Merits of Animal and 
Vegetable Foods in Ninnlion Discussion' speakers 
Dr Tnsiram (St Andrews) Dr Carpenter (Rosvett Institute) 
Dr Blaster fHannoh Dairy Research Institute) Dr Yates 
(Rothamsted Institute) Dr Lucy Wills (Royal Free Hosniial) 
Dr Harnette Chick (Cambridge) and Dr Deane (Cambridge) 
Southeast Metropomtan Regionae Tuberculosis Society — 
At Chest Clinic Health Department Town Hall WaKvorlb 
Road London SE January 20 10 30 for 11 am general 
meeting Clinical programme as follows Tuberculous Can 
ditions of the Skin by Dr W G Tillman Oral Conditions 
in Pulmonary Tuberculosis by Dr G E Kinp Turner discus 
,sion ‘ Domiciliary Treoimenl of Pulmonary Ttiherndops bv 
Dr E K Pnlchard At Bnmswick Tavern Old Kent Road 
London, S E , I 30 p m luncheon 


BIRTHS, MARRIAGES, AND DEATHS ^ 

BIRTHS 

Bttlrtrode ~On January 5 1951 Hartwell Hou^c Harifleld Sussex lu 
Jacqueline (formerly Kent) wife of Dr J C BuUtrode a son 
Bablblt — On December 23 1950 to Stella Murray MB BS DCH 
■ffUe of Dr H S Hablbls a son l 
Boxbes— Oo January I 1951 at Torbay Hospital Torquay to Joy 
(formerly Laxton) wife of Dr D R Hughes a second son—Richard 
John 

Mttrpti> — On D'*rpmh ’O 19^0 Tnei wife of Dr E f Murphy 
Norihowram Hall Halifax a daujrhter 
Sevrs — On December 31 1950 ai Hammersmith Hospital to Dr Janet 
Var^ (formcrlv Conn) wife of Dr H T N Scars a daughter 
I Tbpr^nit — Oi January 3 T9S1 in Trinidad to Gay wife of Dr John V 
Thiif^ion a sifier for Graham — Sheila 
Wefts — On January I 1951 ai Cardiff to Barbara (formerly Sharrait) 
wife of Albert L Wells MB DCP Uandoueb House PenarJb 
Glhia a son 

MARRIAGES 

CoodsoB— Tnyfor — On December 26 19^0 at the Parish Church Tacoma 
Washington USA Michael Piers Ooodson M A MB B Chir m 
Leonora Taylor S R N both of London , 

DEATHS 

Bertram —On December 16 1950 at his home Masons llton Tlminstcr 
Somerset Drummond Rcwcastle Forbes Bertram OBE MB BS 
D M R Surgeon Commander R N retired aged 47 
Caibcjirt — On January 4 J9^1 at South Court Nursing Home Broad tairs 
George Clark Caihcari M D of 11 Upper Wimpole Street London 
VY aged 90 

Cooper— On December 21 19*:0 William Francis Cooper MB BCh 
late ol Hericnnibe Coombe Warren Kingston Surrey 
Coorts— On December 19 19‘iO at 47 Rouge Bouillon St Heller Jersey 
C I Duncan Couits M D F R C O G Lieutenant Colonel i M S 
rrilrcd agro 68 . . 

Fraw— On December 22 1950 at Pitlochry Donald Alexander Fraser 
MBCbBDPH tn.,. 

Prater— On January 2 1951 at 16 Albvn Place Aberdeen Thomas 

FraerCBE D90 TD LLD MB <jhB DPH aged 78 
Freoch — On January 1 19^ at Guy s Hospital London S E Herbert 

Stanley French CVO CBE MD FRCP of Cudworth Manor 
Newdigate Surrey aged 76 ^ 

Gtrdirstnne —On December 30 1930 Gathorne Robert Girdlcstonc D M 
FRCS of Fnlford Heath Berks aged 69 
Colls —On December 2S 1930 at Du Can Court London S W Robert 
C>iIIuro Gully M D formerly of St George a Road Souinwarx 

HaiTfs'^-^n^Deccniher 26 19^0 at 105 Whipps Cross Roa4 
London E Samo on O-oree Victor Hams MD t)PH aged 85 
Heath— On December 23 1950 at Barmouth Merioneth 
Heard M R C S IP CP used 63 
Llnl a —Or December 22 19*^0 at a nursing home Glasgow 

Feirwlck Lin on MB Ch B Lunan Lodge , Renfrew 
Maemmso —On December 24 !9<0 Hugh Agnew Macmillan M C M u 
of The Carnens Meihii Fife ^ . 

Martin —On December 2? 1950 at Elford Douglas Avenue _ 

Qaude Buisl Martin t M O MB CM Colonel 
aged 81 ' 


John RlPPloer 
Robert 


Exmoutb 

A MS fcdred 



Jan 13 1951 


ANY QUE^ONS 7 


British 

Medical Journal 


103 


Any Questions? 


Correspondents should their names and addresses (not 
for publication) and include all rele\ant details in their 
questions u Inch should be ty ped We publish here a selec 
tion of those questions and ansners which seem to be of 
general interest 

Treatment of Psychoses ith A C T H or Cortisone 

Q — treatment with adrenocorticotropic hormone 
(A CT H ) or cortisone likely to help a patient suffering 
from a manic depressne psychosis^ 

A — ^Treatment of manic depressive psychosis by ACTH 
or cortisone is still in the experimental stage It has been 
observed that in mennily healthy people injection of large 
amounts of these substances produces undesirable mental 
changes It would therefore be risky to treat those already 
mentally ill by this means unless full prelautions were 
taken and it would be unjustifiable except as part of a 
controlled experiment A number of psychotic patients 
have however with due regard for these points been 
treated m the United States by investigators primarily con 
earned with the response of the adrenal cortex to stress 
in certain mental disorders M D Altschule' and his 
colleagues in Boston have found that patients with schizo 
phrema and severe depression show greater than normal 
changes m carbohydrate metaboUsm after the injection of 
ACTH and their eosinophil count uric acid and 17 
ketosteroid excretion are not diminished as they would be 
in non psychotic persons given ACTH These investiga 
tors record unsatisfactory results from the clinical stand 
point in a depressed elderly woman the ACTH caused 
hallucinations to develop and she was still extremely 
agitated and depressed after the administration of 570 mg 
of ACTH spread over 17 days a younger woman also 
depressed became rather worse after 900 mg of ACTH 
spread over 10 days others became more tense and rest 
less In Montreal another group of workers* headed by 
R A Clcghorn has administered ACTH to manic as 
well as to depressed patients chiefly to study abnormalities 
of adrenal cortical function m manic depressive disorders 
In the depressed patients a slight iniiial improvement m 
their mental state was followed by some increased tension 
any improvement disappeared quickly when the injection of 
ACTH was stopped A manic patient treated by Clcghorn 
with cortisone for two weeks improved so long as the 
cortisone was being given but it could not safely be con 
eluded that the cortisone was directly responsible for this 
In an investigation in New York City J J Smith* likewise 
found that ACTH m large quantities had not effected 
any clinical improvement in a few patients with agitated 
depression and mama whom he treated 
Refirences 

^ A r-h Neu ot PirchUl Ch^>‘n^n 1950 64 641 

* Canad m d Ass J 19S0 63 325 and 329 

* Quart J Stud At ohol 1950 11 190 

Persistent Urethral Discharge 

Q — A patient of mine has had a sero purulent urethral 
discharge for the last fj\e months Repeated bacterio- 
logical examination confirms the absence of gonococci 
but there is a mixed flora of non haemolytic streptococa 
diphtheroids and small Gram negati\e bacilli Penicillin 
and (he sulphonanudes ha\e failed to clear up the dis- 
charge What further inxestigations and treatment would 
you suggest and is there any likelihood of a subsequent 
urethral stricture de\ eloping ^ 

\ — Before answering the query it should be emphasized 
that thorough cleansing of the meatus with spint should 
precede the taking of specimens for microscopical examma 


tion Most non gonococcal urethral discharges are abacterial 
but inadequate cleansing often leads to the mistaken diag 
nosis that one or more of the normal saprophitic flora is 
responsible for the infection A bacterial (non gonococcal) 
urcthntis is extremely rare such cases as there are being 
either due to mechanical causes (usually the insertion of 
foreign bodies) or secondary to infections of the upper 
urinary tract 

The patient in question is in all probabihl> suffering 
from an abacterial urethritis In these cases there is often 
a history of intercourse during or near a period A possible 
explanation of this is that at such times the cervical canal 
opens up and becomes more vascular and thus allows much 
more epithelium (containing the infective agent) to be 
desquamated into the vagina Such infections are always 
resistant to penicillin and the sulphonamides but aureo 
mycin 05 g eight hourly by mouth for three da>s effects 
a cure in at least 80% of cases Urethral stricture is a 
common sequel when the disease is of long standing Stne 
ture which is never serious can be diagnosed only by 
urethroscopy (it is called urethroscopic stricture ) as there 
15 no diminution in the calibre of the urethra On the other 
hand if the mfection is bacterial hard stnetures as in 
goQOrrboea may occur If further laborator> investiga 
tions show that the condition is bactenal in origin a thorough 
investigation of the upper urinary tract should be carried out 
by a urologist 

Haeroobtic Disease of the Newborn 

Q — I would be glad of your adxice on the following 
cose the mother is Group 0 Rh negatjye the father is 
Group O homoz\pou5 Rh positne (type RhRh-^^Def 
cDE) The only child IS Group O Rh positwe (type Rhirh— 
cDE(cde) The second pregnancy proceeded normally anti 
bodies developing in low litre at the 26th week The tiirc 
gradually rose until the 35th week when they were If 512 
m serum albumin No blocking antibodies e\er de\ eloped 
At the 36th week the litre doubled bur induction of labour 
was not carried out A few days later the child died in 
utero The patient has been told that in all future preg 
nancies the child will be affected and may die in utero or 
if born alive will reauire exsangmnation transfusion Jf this 
IS correct can anything' be done to prexent an antibody 
response ^ Is hapten of any use ^ If treatment w ill not 
prevent foetal damage should the patient be allowed to 
become pregnant again ^ 

A — The question does not give as full details as 
would be desirable If the ^parents concerned have 
the commonest genotypes of the phenotypes slated — i e 
that the mother is rhrh (ede/ede) and the father Rh Rh, 
CDe/cDE) and that the antibody is anti D — then any future 
pregnancy must be expected to yield a child suffering from 
haemolytic disease 

At the present time no method is known by which the 
maternal antibody response can be prevented or the foetus 
protected from the antibodies The extracts which it was 
thought might have contained Rh hapten have not given 
satisfactory results in clinical tnals and their action in 
vitro IS thought to be non specific Such other substances 
as have been tried have been ineffective with the possible 
exception of methionine'-which was thought to be of value 
by N W Philpott M Hendelman and T Primrose (Amer 
/ Obsiet Gynec 1949 57 125) TTieir results have not 
as yet been confirmed by other workers 

The procedures which should be considered in a future 
pregnancy are induction of labour and replacement trans- 
fusion The table below shows the results of such treat 
ment m 46 Rh positive pregnancies in which the mothers 
had borne at least one previous child affected with haemo 
lytic disease The plan of treatment was to induce labour 
surgically at 36 weeks or as soon aftenvards as the foetus 
was considered large enough a minimum weight of 5 to 
5i pounds (2 26 to 2 48 kg ) as estimated by the obstelriaan 
being required before induction w’as allowed All 



ANY QUESTIONS 7 


f 


104 Jan 13, 1951 


the mildest cases of haemolytic disease received a replace 
mem transfusion of one pint of compatible blood within 
a few hours of birth The indications for replacement 
transfusion cannot as yet be laid down clearly but as a 
general rule any child with a positive direct Coombs, test 
and a cord haemoglobin level of under 151 g per 100 ml 
should receive -one Although the serifes quoted is small, 
it shows th It the prognosis for such a pregnancy is not 
hopeless . 



Stillborn 

Neonatal 

Death 

Survived 

Re ' o'- 1 , - 




s* s ! 

Results of latest pregnancies of 27 
mothers whose previous ofTccted infant 

S 

5 

9* 

was born alive 

5 

1 

5 

1 

17 


• Includes one case of kernicterui 


The problem of allowing further pregnancies is one for 
the jiarents to consider after they have been informed of 
the probable risk' If, as is generally the case they decide 
that a further pregnancy is undesirable then advice on 
contraception should be given In the uncomplicated case 
there are no grounds for advising either sterilization or 
termination of pregnancy ' 

1 

Dupuytren’s Contracture 

N 

U — How ihoiiht Dtipiiylrcn s contractmc be treated^ Is 
iiiamin C oj value in this condiitoti^ 

A — ^Thc treatment of Dppuyiren s contracture is still 
entirely an operative one The classical methods of sub 
cutaneous fasciotomy and excision of the affected fascia 
are still ^he two basic procedures fn the past it was 
tustomarjT to use fasciotomy for the mild cases and exci 
Sion of the fascia for the set ere cases The present atti 
■ tude ts the reverse The mild or moderate cases are those 
best suited to excision of the fascii, and in these 'an 
excellent result can be expected In the severely con 
traded cases fasciotomy is performed to explore the possi 
bility of treatment by excision ^In most of them excision is 
of no value as the joints of the finger are commonly still 
or subluxated If a tentative fasciotomy shows this to be 
the case no operative treatment other than amputation is to 
be advised In the operative excision of the fascia it is 
" imperative to remove all skin which is involved in the 
1 Dupuytren process Closure of the skin by means of a 
Z plasty Is a very valuable adjunct to the operation 

It IS almost certain that vitamin E is valueless in this 
condition Various writers have reported success with hqavy 
doses of this vitamin (see British Medical Journal 1949, 2 
1399) while others (for example A R King J Bone Jl 
Siirg 1949 3J B 443) have reported equal failure Many 
of the improvements were of subjective type the patients 
saying that the hands felt softer or the fingers felt straighter 
and that the aching pain bad gone Some observers have 
reported objective improvement in the extension of the 
fingers others have reported failure of improvement in 
objective signs One writer comments that m 12 cases out 
of 13 no value was seen with treatment at full dosage for 
six to eight weeks at a cost of approximately £5 per week 


Adiposis Dolorosa 

Q —Js anything known of the aetiology and treatment of 
adiposis dolorosa ^ 

\ — There is no pathological basis for the differentiation 
of adiposis dolorosa from other forms of adiposity, although 
clinically the name is used if the adipose deposits tend to be 
- painful and the patient depressed or melancholic 

The question therefore involves discussion of the whole 
complex problem of adiposity This also applies to treat 
ment which has been dealt with manv times in these 


, Bmtrh 
\ Medical Journ al 

columns and broadly speaking involves three lines of 
approach dieting and the use of appetite depressors and 
diuretics Thyroid is of limited .value, and there is no 
hormone known which specifically catabolizes fat 

I Urticaria m 8 week old Twin 

Q— f have under my care a bab\ of 8 weeks one of 
tdenttcal twins He iiaj quite well until two weeks ago 
when an urticarial rash dev eloped and he began voiiiitiiig 
he was also constipated Examination showed that the 
colon was loaded with hard faeces and treatment of the 
constipation cured the vomiting However the urticaria 
has ^continued the hands have been grossly swollen and 
huge weals have appeared on the face and trunk On 
the assumption that the urticaria might be due to woollen 
clothes or to the detergent these were washed in the child 
lias given cotton underclothes washed in soapflakes onlv 
In spite of this the condition has persisted and now one 
leg IS grossly swollen The other twin although having 
the same food (national dried milk) and living in the same 
environment is quite well and is non two pounds heaiiei 
than his brother Can you till me (I) What is the youngest 
age at which urticaria occurs (2) Does the fact that one 
twin has reacted differently to the same condition prou 
that the twins are not identical > (3) Is it safe to give anti 
histamine drugs to children of 8 weeks and if so* ii /ml is 
the dosage 

A — ^The answers to the three questions are (1) Urticaria 
may appear at any age and has been reported in the new ' 
born (2) A different reaction to the same condition m 
twins does not prove that they are not identical because 
other factors may not be the same but in general one vtioiild 
expect identical twins to react in the same way (3) The 
antihistamine drugs at present dh the market can safely be 
given to infants who seem to tolerate them better than most 
adults The dose vanes according to the drug used but 
those for which a single adult dose is 25 mg can be given 
in 10 mg doses up tq a total daily maximum equal to 
about 3 mg per pound (0 45 kg) of body weight 

It IS rather unusual for an allergic reaction to cause such 
persistent swelling of the limbs Is it possible that some 
other condition iSj present as well as an allergic reaction 
with urticaria Vomiting and urticaria in a bottle fed 
baby suggest a milk allergy although colic and loose fatty 
or undigested stools would be expected rather than constipa 
tion It IS important to find the allergen before exhibiting 
antihistamine drugs, and it would be best to place the child 
on a boiled water or glucose water diet for a couple of 
days to see if the symptoms disappear It they do then 
It would be wise to feed the child upon a soya bean prepara 
tion before attempting to desensitize him to cow s milk 
The delay in the appearance of symptoms docs not rule 
out the possibility of sensitivity to cow s milk 

NOTES AND COMIWENTS 

Correction — In the obituary notice of Sir Leonard Parsons 
which was published in the Journal of December 30 1950 it vns 
wrongly stated that Sir Gilbert Barling was co editor with Sir 
Leonard Parsons of Disease in Infancy and CInIdIwod It was 
Mr Seymour Barling who was co editor of this textbook 


.11 communications ‘with rcaard to editorial business should be addre^cd 
lo The editor Bmtish Medical Jouenal B M A House Tavistoce 
Sqoake London W C I Telephone EUSTON 211 1 ,,, T‘i‘'rTTc» s 

Aitiotogy VVesIcenI London ORIGINAL ARTICl^S AND LETTE 
lorwardcd lor publication arc undcrslood to be ottered to the ariasn 
Mrdical Journal alone unless the conltary be staled. - 
uUtors dcslrinc REPRINTS should communicate with the Piibb bine 
Manaeer B M A House Tavistocb Square W C I on receipt of proms 
Authors oerstais should Indjcaie on MSS »f reprints arc required 
proofs are not sent abroad . _ . 

DVERTfSEMENTS thoJld be addressed lo ^ id 

B M A Hou r Tavistock Square London W C I (hours 9 J 
5 pro) Telephone EUSTON s2111 Telegrams Drltmedads 

[msSS SUBSCRIPTIONS should be sent to the SECRETARY of ^ 
Aasociahon Telephone EUSTON 2111 Telecraa<s Mtnse 
tVestcent Lonaon . . 

A JsroTTi.cH Office 7 Drumsheugh Gardens Edinburgh 



LO>DON SATURDAY JANUARY 20 1951 


HORMONES OF THE SYMPATHETIC NERVOUS SYSTEM AND THE 

ADRENAL MEDULLA" 

U S >on EULER, MD 

(From the Department of Physiolog\ KaroUnska Institute Stockholm) 


The substances which determine the action of adrenergic 
nerses and of the internal secretion of the adrenal 
medulla are of equal interest from the physiological and 
the pharmacological point of Mew In the elucidation 
of this problem as a whole pharmacological methods of 
analysis have largely been used, and with considerable 
success, demonstratmg the value of pharmacological tools 
in solving physiological and even chemical problems 
The concept of a neurohumoral transmission of nerve 
impulses takes us back to Elliott (1905) in England who, 
on account of the similarity of action of sympathetic 
nerve stimulation and adrenaline propounded the hvpo 
thesis that such nerve impulses became effective by 
liberating adrenaline at the nerve endings To prove 
this was not so easv however and in spite of several 
attempts it was not until 1921 that Loewi in Graz and 
Cannon and Uridil in Boston, demonstrated the release 
of an active adrenaline like substance as a result of 
sympathetic nerve stimulation It v/as as in Elliotts 
day considered almost self evident that this substance 
was adrenaline At a time, however, when everybody 
else seemed to be satisfied with the identitj of the actions 
of adrenaline and sympathetic nerve stimulation, Barger 
and Dale (1910-11) in their classical study on sympafho 
mimetic amines noted significant differences in this 
respect, and also pointed out that better agreement was 
found with the non methylated ethanol amino base 
noradrenaline This most important recognition was 
however overlooked for a long time and as late as 
1939 Cannon and his co workers believed that adrenalme 
was the mediator of the adrenergic nerves 



CH(OH)CH, NH(CH,) CH(pH)CH, NH, 

Adrenaline lYoradrem me 

Cmeth>lanunoethanolcatechol) 

On the other hand Cannon and Rosenblueth (1933) 
discovered that stmiulation of sympathetic nerves pro 
duced actions which necessitated the assumption of two 
different active substances which were called sympathm I 
and E owing to their inhibitory and exeitatory actions 
These substances were believed to be formed by the 

•Lecture given b> invitation of the University of London al 
St Mary s Hospital on October 17 1950 


interaction of the mediator and constituents of the 
reacting cells With increasing knowledge of the action 
of sympathomimetic amines the idea gradually dev eloped 
however, that noradrenaline might be responsible for 
the excitatory reactions and adrenaline for the inhibi 
tory ones (Bacq 1934 Melville 1937 Stehle and 
Ellsworth, 1937 , Greer et al 1938) although these con 
cepts did not seem to become generally accepted 

A closer analysis of the sympathomimetic action of 
suitably purified extracts of organs and nerves, under 
taken in our laboratory in 1944-6 revealed however 
that the responsible substance or substances differed dis 
tinctly from adrenalme in several respects (Euler 1946) 

The suspicion that the activity might be due to nor 
adrenaline proved fruitful, and it could be shown by 
various biological and chemical tests that there was a 
close agreement between the actions of the extracts and 
noradrenaline Holtz et al (1947) demonstrated inde 
pendently the probable presence of noradrenaline in 
urine and m suprarenal extracts In the same year 
Gaddum and Goodwm (1947) showed that the substance 
liberated on electrical stimulation of sympathetic nerves 
could be noradrenalme and shortly aftenvards Folkovv 
and Uvnas (1948) obtained evidence for the liberation 
of noradrenaline in vascular reflexes in the cat Tu'lar 
(1948) succeeded in resolving racemic synthetic nor 
adrenalme, or arterenol into its optical isomers and 
L-noradrenalme became available By biological and 
chemical methods the active sympathomimetic principle 
m nerves and L noradrenaline were shown to have a 
close agreement, strongly supporting their identity 

The pharmacology of noradrenaline then naturally 
aroused great interest, and some of its more important 
actions are mentioned below, especially in comparison 
with Its more time-honoured and well known homologue 
adrenaline 

Action on Smooth muscle Organs 

As already noted by Barger and Dale, noradrenalme 
has a rather weaker i^ibitory effect than adrenahne on 
smooth muscle organs, such as the uterus and intestine 
of the cat Large variations m the effects occur, how ever 
on oifferent organs Thus the relative effects on the 
intestmc do not differ much adrenaline being only about 
twice as active at most On the rats uterus on the 
other hand the inhibitory action of adrenaline may 




106 Jan 20 1951 


HORMONES AND THE ADRENAL MEDULLA 


BumsH 

Medicai. journal 


as much as 300 times stronger than that of noradrenaline 
Other organs, such as the ins, the cat s uterus, bronchial 
muscles, and the fowl s rectal caecum, are intermediate 
in their responses 

An interesting feature in the response to the two 
catechol derivatives has been observed by Burn and 
Hutcheon (1949) after denervation of the nictitating 
membrane in the cat the sensitivity is increased only 
moderately for adrenaline but up to nine times for nor- 
adrenaline I shall not enter into a discussion of this 
remarkable change in action It has been suggested that 
It IS due to the possible removal by denervation of 
normally occurring inactivating enzymes 
In contracting the uterus of the pregnant cat nor 
adrenahne is more active than adrenaline 

Action on Heart and Circulation 
Some of the most conspicuous actions of noradrenaline 
and adrenaline are their circulatory effects Whereas 
adrenaline produces the vvell known rise in systolic blood 
pressure, it has only little action on the diastolic pres- 
sure , in fact, this may be lowered leaving the mean 
pressure almost unchanged The minute volume of the 
heart is increased Again,'-thc unaltered level of mean 
blood pressure in conjunction with the increased minute 
volume signifies that the sum total of the vascular effects 
of adrenaline is a vasodilatation This is in sharp con 
trast to the effect of noradrenaline, which produces an 
almost parallel rise in systolic and diastolic blood pres 
sure and also bradycardia (Barcroft and Konzett, 1949 , 
Svvan^ 1949 Kappert et al , 1950) Noradrenaline in 
moderate doses produces no change in the minute-volume 
of the heart, and since the mean blood pressure rises 
one must infer a general vasoconstriction (Goldenberg 
el al , 1948) 

-The only vascular areas which so far have been found 
to respond to noradrenaline with vasodilatation are the 
coronary arteries and possibly the intestinal vessels when 
small doses are employed Noradrenaline also has a 
smaller constrictor action on the renal blood flow than 
adrenaline (Burn and Hutcheon, 1949) 

It isinot surprising that noradrenaline has been linked 
with hypertension, since many features in hypertension 
seem to be consistent with an action of noradrenaline 
Goldenberg et a! (1948) have measured the blood 
pressure-raismg effect of a constant infusion of nor 
adrenaline in various doses on normotensive and 
hypertensive patients and observed a rather stronger 
response in hypertensives The reason for this differ- 
^ence, which has also been noted by Moeller and 
Koppermann (1950), has not yet been elucidated, how- 
ever If the reason were a relative insufficiency in the 
inactivation of noradrenaline one might expect to find 
an increased output of the catechol amines in the urine 
but this does not seem to be the case, in essential 
hypertension at least 

Action on the Metabolism 
The calongenic action of adrenaline has been known 
for a long time, and has been demonstrated not only 
on the total oxygen consumption in animals and man 
but also on isolated organs and minced tissues In man 
a dose of 0 01 mg per kg given subcutaneously will 
increase the oxygen consumption by some 25% Nor 
adrenaline is much less active in this respect as borne 
out by a series of recent investigations in animals and 
man Goldenberg and his associates found hardly anv 


action at all on infusion of 0 15 jtg of noradrenaline 
per kg per minute in man, m contrast to adrenaline, 
which in the same dose increased oxygen consumption 
by some 25% Bigger doses of noradrenaline had a 
moderately stimulating effect on the metabolism 
The glycaemic effect of noradrenaline is likewise much 
less marked than that of adrenaline, and the relative acti 
vity has been estimated at about 1 10 Also, nor 
adrenaline is less active in the formation of lactic acid 
The recent increase in interest in the pituitarj-adrena! 
system, m connexion with the use of cortical hormones 
and A C T H in the treatment of chronic arthritis and 
other conditions, has directed attention to the mechanism 
of the release of these hormones It has been shown 
that adrenaline is effective in hberating cortical bor 
mones and also that this effect is mediated by the hypo 
physis The fall in blood eosinophils caused by adreno 
cortical hormones has been used as a quantitative test 
of the release of A C T H , and the effects of adrenaline 
and noradrenaline m this respect have been compared 
Humphreys and Raab (1950) found noradrenaline to be 
only one sixth as active as adrenaline Also adrenaline 
IS more active in decreasing the ascorbic acid content 
of the suprarenals (Nasmyth, 1949) 

Differences iii action between the two catechol deriva 
tives have also been noticed vvith regard to the effect 
on the central nervous system It is a common obser 
vation that in man adrenaline produces a peculiar feel 
ing of anxiety, discomfort, and irritation Noradrenaline 
in doses which cause a much larger rise in blood pres^ 
sure, has no such effect, or a rather weak one 

Toxicity 

An interesting difference between adrenaline and nor 
adrenaline from the pharmacological point of view has 
been observed as regards toxicity Already in 1906 
Biberfeld had noted that noradrenaline was considerably 
less toxic than adrenaline for rabbits and rats This 
has been confirmed by Tamter et al (1948) who found 
that L-zioradrenaline was no less than eight tunes less 
toxic on mice in single cages than L-adrenaline 

Out of these differences in action one may draw 
certain conclusions not only about the nature of the 
physiologically active catechols but also about the indi 
cations when these substances are to be used as thera 
peutic agents Adrenaline has been used, sometimes 
rather indiscriminately, in circulatory collapse, a use 
which IS largely based on an erroneous conception ot 
its mode of action Por the restoration of blood pres 
sure noradrenaline is much better suited than adrenaline 
and has already proved valuable in combating low hlo™ 
pressure in operational shock It may be administerw 
with advantage as an infusion Noradrenaline would 
also cause less disturbing side actions when used as a 
vasoconstrictor togetherwithjocal analgesics The sails 
factory actions of adrenaline in counteracting circula 
tory collapse sometimes noted, may well be due to the 
fact that the so called natural adrenaline ’ on the 
market may contain up to 20% noradrenaline 

Some Chemical Properties 
Adrenaline and noradrenaline may be chemicallv 
separated from each other either by pure chemical 
methods, using the difference m solubility ot certain 
salts, or by partition in different solvents Craigs 
counter current distribution technique allows a goon 
separation when phenol and 0 02/N HCl are use as 
solvents 



Jan 20 1951 


HORMONES AND THE ADRENAL MEDULLA 


BRimii 

MEDICAI. JOUllNAl. 


107 


Also partition chromatographj on starch columns 
and paper chromatography, may be used N butanol 
hydrochloric acid or phenol-water mixtures have prored 
useful 

/Voradrenaline shows a greater resistance to oxidation 
than adrenaline Thns a solution of noradrenaline at 
pH 3 5-4 IS very slowly oxidized by iodine to the 
coloured product lodonoradrenochrome whereas adren 
aline is rapidly oxidized An interesting difference is 
also found m the fluorescence in ultra violet light of 
oxidation products of the two substances The fluor- 
escent substance formed by noradrenaline (noradreno 
lutin) emits a less intense light than does adrenolutin 

Estimation 

Noradrenaline may be assayed biologically or colon 
metrically against a chemically pure standard Usually 
the problem is complicated by the fact that noradrenaline 
almost always occurs together with adrenaline which 
necessitates a more complicated procedure However 
the variations in the activity ratio of adrenaline and 
noradrenaline on vanous test preparations make it pos 
sible to estimate the two catechols in a mixture A 
useful pair of test preparations is the cat s blood pres 
sure where noradrenaline is some two to four times 
more active than adrenaline and the fowls rectal 
caecum or the rats uterus where adrenaline is much 
more active than noradrenaline 

The extract is evaluated m terms of either one of the 
two catechols against a standard and the relative acti 
vity of the two catechols determined in the two tests 
By a simp’e formula (Euler, 1949), the amount of each 
catechol can be computed This procedure of course 
necessitates extracts which are essentiallj free from any 
contaminating active substance Adsorption on alumina 
gives satisfactory extracts If the amounts of catechol 
derivatives are large enough as for instance in supra 
renal extracts, the assay can be made colorimetrically, 
which IS simpler In this case use is made of the dif 
ferent oxidation velocities at pH 4 and pH 6 At pH 4 
all of the adrenaline is oxidized to the coloured com 
pound in one and a half minutes whereas only some 
10% of the noradrenalme is oxidized At pH 6 all of 
the adrenaline and /loradrenaline is oxidized to the 
coloured compound in three minutes A simple calcula 
tion gises the actual amounts of the two substances 
(Euler and Hamberg 1949) 

Distribution 

Noradrenaline is widely distributed in the body and 
has in fact been found in all nerves containing adrenergic 
fibres and consequently m almost all organs and tissues 
including the blood and also in aqueous humour urine 
and glandular sccrebons Only the placenta and perhaps 
the bone marrow seem to lack these ergones In the 
placenta there are no nenes and in the bone marrow 
one could imagine that there would be little need of 
vasomotor nerves since there is no margin for expan 
Sion or contraction The amounts found in tvpical 
adrenergic nenes such as the splenic nencs are quite 
large (1&-20 pg per g) In the spleen the content is 
considerable (3-4 pg per g ) indicating that the pen 
pheral parts of the nerves contain comparativelv large 
amounts The content in the heart is also relatively 
large In the central nervous system no more than 
0 2 pg per g was found (rabbit) — that is something 
like I % of the content of the splenic nerves The same 
IS the case for histamine 


The amount of adrenaline occurring together with 
noradrenaline in adrenergic nerves and organs is usually 
only a few per cent of the total catechol amines, show 
ing that noradrenaline is the dominating adrenergic 
neurohormone The Table shows the abso'ute catechol 
amine content (in pg per g ) of some organs and nerves 
and also the relative amount of adrenaline After stimu 
lation the two substances apparently are released in 


Organ 

[ Cow 

1 Sheep 

Tefal 
Catechol 
per 8 

Adrenaline 

Total 

Catechol 

perg 

/ 

Adrenaline 

Spleen 

1 1-2 6 

4-1 1 

1 6 

5 




26 

3 

Heart 

0 2-0 4 : 

20-26 

09 

20 

Lung 

1 


008 

25 

Brain 

0 02 1 

13 



Kidney 

0 1 

4 



Striated mu&cle 

OOl 


0 03 

5 

Lymph gland 

08 


03 

25 

Submaxillary gland 



Ofr-l I 

15-37 

Splenic nerves 

7 6-9 6 

11-3 5 1 

5 1-8 3 

1 2-7 

Mesentenc nerves 

3 


1 1-1 3 

- 2-« 




3 5“ 

2 

Vagus ncr es 

1 0 1 


0 5-1 5 

4 5-7 5 

Sympatheiic trunk 

2 5-5 ' 


1 1-3 8 

1 6-7 5 

Sciatic trunk 

1 

1 

0 18 

7 


about the same proportion as they occur in the nerve 
(Peart, 1949) After denervation the content in the 
nerve and the corresponding organs diminishes greatly 
so as to leave even less than 0 5 % of the original amount 
(Cannon and Lissak 1939 Goodall 1950b) 

Occurrence in Blood and in Urine — Noradrenaline 
seems to be normally present in small amounts in the 
venous blood of man and animals In purified extracts 
It has been demonstrated biologically in amounts of the 
order of 1-2 pg of noradrenalme per 100 ml of blood 
(Euler and Schmiterlow 1947) It is likely that some 
adrenaline is also present in the blood The presence 
of the catechol amines in the blood is also compatible 
with the fact that they occur normally in urine as shown 
originally by Holtz el al (1947) and confirmed by us 
The larger part is present in a free form but apparently 
some IS conjugated and may be liberated by acid hydro 
lysis The amount m the urine of normal man is of 
the order of 30 pg of L noradrenalme a day and some 
10 pg of L adrenaline 

Siiprarenals and Chromaffin cell T amours — ^The first 
intimation of the presence of noradrenalme in the supra- 
renals was made in 1947 by Holtz and his associates 
Their findings were soon confirmed and extended, by 
several groups m vanous countries It was isolated from 
suprarenal extracts m 1949 (Bergstrom, Euler, and 
Hamberg 1949) By using paper chromatography the 
separation of noradrenalme and adrenaline was first 
demonstrated by James (1948), and this method also 
indicated that these two catechol derivatives were the 
only ones to be found normally in most 'suprarenal ' 
extracts The relative amounts of adrenaline and nor 
adrenaline varj greatly in different animals and also in 
the same animal during different conditions In the 
rabbit almost all of the catechol amines are adrenaline 
but in the cat the noradrenalme may constitute more 
than 50% of the total In chromaffin cell tumours the 
noradrenalme content maj be very high as originally 
shown by Holton (1949) and confirmed b> severaf other 
authors In other cases however adrenaline and nor- 
adrenaline mav occur m about equal amounts depend 
mg on the site and nature of the tumour ^ 



108 Jan 20, 1951 


HORMONES AND THE ADRENAL MEDULLA 


British 

Medical Journal 


Fonnahon and Fate in the Body 
The discovery of Holtz and associates that animal 
organs contain an enzyme capable of decarboxylating 
dihydroxyphenylalanine (D O P A ) into hydroxytyr- 
amme (L-dopa decarboxylase) indicated a possible way 
of formation of noradrenaline, as already pointed out 
by Blaschko in 1942 Langemann (1950) found dopa 
decarboxylase in considerable quantities in suprarenals 
An important contribution has been made by Goodall 
(1950a), who found certain amounts of hydroxytyramine 
in normal sheep s hearts He also demonstrated DOPA 
in sheep suprarenals after thyroidectomy Hydroxytyr- 
amine seems to occur regularly in urine One may 
therefore depict the formation of noradrenaline along 
the following hnes 

OH 

P|OH _co. 

CHjCHCOOH 

kn, 

DOPA 

The process by which a hydroxy group is introduced 
in the side chain is still unknown, although it has been 
observed to occur in vitro 

Noradrenahne is partly inactivated by means of an 
amine oxidase and a catechol oxidase in the body, and 
partly eliminated in the urine, where it appears chiefly in 
free form 

On certain occasions the amounts excreted are rather 
higher than normally, as, for instance, in muscular work 
(Euler and Hellner, 1951) and in cases of chromaffin-cell 
tumours In the latter cases excretions amounting to 
more than 1,000 /ng a day have been observed (Engel 
and Euler, 1950), a circumstance which has been utilized 
as a way of diagnosing such tumours In such cases the 
urine may be assayed directly on the cat s blood pressure 
Highly interesting are the findings of Blaschko and 
Burn (1950) concerning the inactivation of a mixture 
of noradrenaline and adrenaline by means of an amine 
oxidase preparation from rabbit liver They found that, 
as incubation proceeded, the relative amount of nor 
adrenaline steadily fell from 50 to 10% and the per- 
centage of adrenaline rose from 50 to 90% Indepen- 
dently Udd^n m our laboratory found that noradrenaline 
IS much more readily inactivated on mcubation with 
splenic nerve tissue of cattle than is adrenahne 
The form in which noradrenaline and adrenahne are 
present in the nervous tissue is still unknown However 
both catechol ammes form ether-soluble compounds with 
lecithin In equilibrium with a water phase the amounts 
taken up by the lecithin ether are greatly dependent 
on the pH Thus at pH 7 some 25-30% of the catechol 
amines may occur in the ether-lecithin phase, whereas 
at pH 5 only some 5% is bound to the lecithin in ether 
solution (Norlander, 1950) 

One may imagine that the catechol ammes could be 
bound to phosphatids m the nerve and liberated by a 
shift in acidity 

Significance of Noradrenaline in the Body — The sig 
nificance of the occurrence of noradrenaline m the 
organism has been questioned in some quarters where 
It IS thought that noradrenaline is merely a precursor of 
adrenahne and serves no independent function This is 
however, m obvious opposition to the findings that the 



CH,CH,NH, CH(OH)CH,NH, 

Hydroxytyramine Noradrenaline 


normal reflex vascular effects in reality are effectuated 
chiefly by noradrenaline It appears that noradrenaline 
IS the sympathetic neuro ergone for general service, the 
adrenahne acting as an adjuvant for more special pur 
poses, especially as regards metabolic actions 
Alterations in Distribution of Noradrenaline and 
Adrenaline — ^A disturbance in the v distribution of the 
two catechol ammes is encountered in connexion with 
various endocrine disturbances, such as after hypo 
physectomy, in thyrotoxicosis, after thyroidectomy, and 
in other conditions This applies to the suprarenal 
medulla, and other organs as well In the rat’s spleen, 
after hypophysectomy, the adrenaline percentage is con 
siderably increased (Euler and Hokfelt, 1950), and after 
thyroidectomy it is markedly decreased (Goodall, 1950b) 
A large field is opening up here which may be of interest 
for the interpretation of certain vegetative disorders in 
connexion with hormonal imbalance 


References 

Baca Z M (1934) Ann Physiol Physicochim biol 10 467 
Barcroft H , and Konzett H (1949) ] Physiol 110 194 

BarEer, G and Dale H H (191(3-11) Ibid 41 19 
Ber£strom S Euler U S v and Hamberg U (1949) Acta 
chem scand 3 305 

Biberfeld J (1905) Med Klin 2 1177 

Blaschko H (1942) 1 Physiol 101 337 , . 

and Bum J H (1950) Physiol Soc Meeting at Oxford 

July 1950 To be pubhshed 

Bum J H and Hutcheon D E (1949) Bnt J Pharmacol 
4, 373 ^ 

Cannon W B , and lissik K (1939) Amer J Physiol 125 
765 

and Rosenbluelh A (1933) Ibid 104 557 

and Undil J E (1921) Ibid 58 353 

Elhott T R (1905) J Physiol 32 401 ^ 

JEngel A , and Euler 13 S v (1950) Lancet 2 387 
Euler 13 S V (1946) Acta physiol scand 12 73 

(1949) Ibid 19 207 

and Hamberg 13 (1949) Ibid 19 74 

and Hellner S (1951) To be pubhshed 

and Hokfelt B (1950) To be pubhshed ^ , 

and Schmiterlow C G (1947) Acta physiol scand 13 1 

Folkow B, and Uvnas B (1948) Ibid 1^365 
Gaddum J H and Goodwm L G (1947) / Physiol 105 

357 

Goldenberg M Pines K L Baldivin E F Greene D G 
and Roh C E (1948) Amer J Med 5 792 
Goodall McCh (1950a) Nature Land 166 738 

(1950b) To be published , . 

Greer C M Pinkston J O Baxter J H and Brannon X 5 
(1938) J Pharmacol 62 189 
Holton P (1949) Nature Land 163 217 
Holtz P (ireoner K and Kroneberg (3 (1947) Arch exp 
Path Pharmak 204 228 „ , 

Humphreys R 3 and Raab W (1950) Proc Soc exp Biol 
NY H 302 

James W O (1948) Nature Load 161 851 , 

Kappert, A Sutton G C Reale A Skoglund K H and 
Nylin G (1950) Acta cardiol Brux S 121 
Langemann H (1950) Abstr Comm 18 int Congr Physiol 
Copenhagen 

Loewi O (1921) Arch ges Physiol 189 239 
Melville K I (1937) J Pharmacol 59, 317 . , 

Moeller J , and Koppermann E (1950) Z KreislForsch 39 
333 

Nasmyth P A (1949) J Physiol 110 294 
Norlander O (1950) Acta physiol scand To be published 
Peart W S (1949) J Physiol 108 491 „ 

Stehle R L and Ellsworth H C (1937) / Pharmacol 59 

114 

Swan H J C (1949) Lancet 2 508 

Tamler M L Tullar B F and Luduena F P (1948) Science 
107 39 

TuUar B F (1948) J Amer chem Soc 7* 2067 


Miss Edna Jackson has been appointed a Deputy Chief 
Nursing Officer of the Ministry of Health in succession to 
Mrs E Harman who has resigned following her marriage 
Miss Jackson s duties cover a wide field of public health 
nursmg, particularly in relation to mothers and young 
children midwifery home nursing and the preventive 
health services of the local health authorities She was 
previously Public Health Nursmg Officer in the North west 
Region of the Ministry 



Jan 20, 1951 


AGGLUTININ ANTI S IN HUMAN SERUM 


B JTmi 

Medical Journal 


109 


AGGLUTININ ANTI-S IN HUMAN SERUM 

H I COOMBS, MA, PhD, MD 
ELIZABETH W IKIN, B Sc 
A E MOURANT, MA, DPhil, DM 

AND 

GERTRUDE PLAUT, BA, MD 

(From St Bernards Hospital Southall Medical Research 
Council Blood Group Reference Laboratory Lister 
Institute and the North London Blood 
Supply Depot Barnet) 

The antibody anti S was first discos ered by Walsh and 
Montgomery (1947) in the serum of a puerperal patient 
whose fifth pregnancy had resulted in the birth of a 
macerated and oedematous 'oetus Her second child 
had died ot haemolytic disease of the newborn , the 
third and fourth pregnancies had ended in early mis 
carriages Her serum was found to contain anti D 
together with an unidentified antibody which aggluti 
nated the red cells of 48 6% out of a total of 253 
Australian individuals chosen at random The agglu 
tinin reacted most strongly at 37 C , but was also active 
at lower temperatures It did not sensitize cells to the 
Coombs test 

The corresponding antigen S was shown by Sanger 
and Race (1947) to be very closely related to the MN 
blood group system m a manner similar to the relation 
between the C, D and E antigens of the Rh system 
The simplest explanation of the experimental results is 
that two genes, S and s exist and that either one or the 
other is always very closely linked to each M and N 
gene, thus giving rise to four possible chromosome 
arrangements — MS Ms, NS or Ns Each individual has, 
of course, two such chromosomes, and these would there 
fore give rise to 10 possible genotypes or combinations 
of two chromosomes as shown in the accompanymg 
Table The red blood cells of any person possessmg 


The ^^NS Phenotypes Based on o Paper by Race Sanger LanJer 
and BerlmshaM (1949) 


Genotypes in 
Each Phcnot>pe 

1 

Reactions of Pheno- 
type with Antisera 

Full 

Ph noiype 
Symbol 
(RacsetuI 
1949) 

Symbol 

Used 

n 

this 

Paper 

Frequency 
of Phenotype 
lo British 
Population 

Aati 

M 


S 

MSMS MSMs ! 

+ 

_ 

+ 

MMS 

MS + 

21/ 

MsMs 1 

+ 

— 

— 

MsMs 

MS- 

V 

MSNS MSNs 1 







MsNS 

+ 

+ 

+ 

MNS 

MNS + 

28/ 

MsNs 1 

+ 

+ 

— 

MsNs 

MNS- 

22/ 

NSNS NSXs ; 

— 

+ 

+ 

NN S 

NS 4- 


NsNs 

“ ' 

+ 


NsNs 

NS- 

13/ 


944 persons comprises 140 Australians nearly all of Bntuh onsin and 
804 English 


either one or two S genes as m lines 1, 3 and 5 of the 
table, are agglutinated by anti S serum Not all the 
genotspes can be distinguished from one another by 
serological means Each group of serologically indis- 
tinguishable genotjpes constitutes a phenotype, of which 
there are six one to each line of the table In the last 
column are given the percentage frequencies of thepheno 
types among 944 unselected English and Australian per- 
sons as reported by Race, Sanger Lawler and Bertinshaw 
(1949) One notable feature is that most English bloods 


containing M also contain S while most N bloods do 
not contain S All the observed facts with regard to the 
distribution of the S antigen in the population as a 
whole and to its inheritance in individual families can 
be explained on the above mentioned theory that there 
are two genes, S and s, which are very closely linked to 
M or N (Sanger Race, Walsh and Montgomery, 1948 
Race, Sanger, Lawler, and Bertinshaw 1949) 

A second example of anti S was discovered by Pickles 
(1948) m the serum of a mother who subsequently gave 
birth to a stillborn infant As in the above mentioned 
case, anti D was also present with the anti-S Three 
weeks before parturition the titre of anti-S was one 
Three weeks after delivery it had risen to 16, and six 
weeks after delivery it was eight These changes in titre 
suggest that the production of anti S m this case was 
due to an immune reaction, and an investigation of the 
blood groups of the family gave support to this theory 
The ABO Rh, MNS groups of the family were as 
follows 


Mother 

Father 

Surviving child 
Slillbom infant 


A R"r 
O R.R, 
A Rh+ 
A Rh+ 


M S- 
MN S+ 

M S-i- 
Direct 

Coombs test 
positive 


Further support for the suggestion that the production 
of anti S in this case was the result of an immune 
reaction is given by the finding that the antibody was 
more active at 37 C than at 20° C It has been men 
tioned above that this lessening of activity with decrease 
of temperature was also found in the case of Walsh and 
Montgomery (1947) and probably for a similar reason 
In this case and the previous one the presence of anti D 
prevents us from knowing whether anti S was m any 
way responsible 'for the haemolytic disease of the 
foetus 

A third example of anti S was found by Cutbush 
and MolUson (1949) following the transfusion of an 
unmarried woman who had never been pregnant She 
had received six transfusions of blood of unknown Rh 
and S type without reaction, but after the seventh trans 
fusion of similar y untyped blood she had a ngor and 
was then found to be Rh negative Her subsequent six 
transfusions were of Rh negative blood but she never- 
theless had reactions after most of them and in one case 
the transfused cells were very rapidly disappearing from 
her circulation It was then discovered that, m addition 
to the anti D contained in the serum of the patient, there 
was also anti-S and thereafter transfusions were of 
Rh negative, S negative blood Even blood of this type 
was rather rapidly eliminated showing the presence of 
yet another kind of sensitivity which was not fully 
explained In this case the antibody sensitized S positive 
cells to the Coombs test, a fact which is suggestive of an 
immune origin It is also almost certain that some, at 
least, of the first six transfusions consisted of S positive 
blood, and as these gave rise to no reaction, httle if any 
anti S could have been present in the patients serum 
before the transfusions were begun It is moreover, 
highly probable that anti S was the cause of the reac 
tions which followed most of the transfusions from the 
eighth to the thirteenth 

An example of anti S unaccompanied by anti-D has 
been described bv Race Holt, Gorius and Bessis (1949) 
as occurring in the serum of a patient after numerous 
transfusions for haemolytic anaemia The antibody 
reacted equally well at room temperature and at 37 C 



110 Jan 20, 1951 


AGGLUTININ ANTI-S IN HUMAN SERUM 


Buthh 

Midical Journal 




cdc/ede 

MsMs 

P- 

Anci S absent 


/ Patient 

t Deceased not tested 
Q Male 
O Pemale 
O Miscarriage 


In another case of multiple'transfusipns investigated 
by Collins, Sanger, Allen, and Race (1*950) The patient 
developed a large number of antibodies, including anti S 
and the Rh antibodies anti-E and anti C" Waller and 
Race (personal communication, 1950) have found anti-S 
together with the Rh antibodies anti C and anti-B and 
several other abnormal agglutimns in the serum of a 
male Negro who had received numerous transfusions 
These two cases are similar to one described by Callender 
and Race (1946) in which, following a series of trans 
fusions, numerous antibodies were formed, which did 
not, however, include anti S 

Da Silva Lacaz, Ikin and Mourant (unpublished data, 
1950) have investigated the serum of a patient who after 
several transfusions died following 
a haemolytic reaction Her serum 
was found to contain anti C, anti D, 
and anti S Molhson (1950) has 
described the case of a woman 
who after several transfusions and 
several pregnancies, two of them 
ending in stillbirths due to anti D, 
had a clinically unaffected Rh- 
negative babv with a weak posi 
tive direct Coombs reaction The 
mother was then found to have 
anti-S as well as anti-D in her 
serum 

Rosenfleia and Vogel (personal 
communication, 1950) have detected 
naturally occurring anti S as the 
sole abnormal antibodv in the serum of a routine blood 
donor An account of this case will shortly be published 
ThftMNS blood group system has recently been described 
as a whole in some detail by Race and Sanger (1950) 

Report of a Further Case 

The authors have investigated the case of a patient who 
was born in 1894 and married in 1915 She had four mis 
carriages each at seven months in 1917 1919 1921 and 
1923 One son was born in 1925 and is alive and well 
Three of the miscarriages followed severe accidents and 
were thought by the patient and her husband to have been 
thus caused The patient said that the fourth was induced 
by herself 

Early in 1948 she complained of fatigue weakness 
breathlessness and progressive numbness and coldness of 
the hands She was admitted to Hill End Hospital 
SL Albans on September 18 1948 The blood findings 
were urea 120 mg per 100 ml serum protein 52 g 
per 100 ml haemoglobin 22% Haldane red cells 
1 800 000 per c mm white cells 7 800 per c mm On 
account of the severe rnaemia it was decided to give her 
a transfusion but attempts at direct matching showed the 
presence of an unusual agglutinin in her serum This was 
quickly identified as anti S but before compatible blood 
could be obtained and administered she died 


Serology 

Shortly after death a considerable volnme of blood was 
withdrawn from the heart and large arteries by means of a 
syringe and needle The serum from this blood has been 
a valuable source of anti S for testing purposes having been 
distributed to many laboratories The absence of admixed 
anti Rh greatly simplifies its use.as a testing reagent 
Comparison of the reactions of the serum with the original 
anti S serum of Walsh and Montgomery showed that their 
specificity was identical The serum of our patient how 
ever, reacts more strongly at room temperature than at 
37 C The blood groups of the patient and her relatives 
are shown in the diagram Since the hasband and surviving 
child are S negative and careful inquiries have yielded no 


to- 


-Dt 


CDeTcdt 

MjNj 

P~ 

S absent 


A O 
cde/cde 
MSMs 
P+ 


CDe/3e 
MSMi 
P- 


IsAlS 


CDe/c(le 

MtMs 

P- 

Anti S Absent 


5 ^ 

/ue cde/cdo 


BC 

cde/cdo 

MSNs 

P+ 


CDe/cD 
or Cdo/cDe 

MiM» 

P+ 


O B 


cde/cd# 

MiKc 

Ant) S pmseni 


□ cDe/cde 


MtNs 

- P+ 

Blood groups of the patient s family All surviving members (except the patient) were 
tested with anti Kell and anti Lua with negative results All of these who were of group 
A or O were also found to be negative to anU Lea The absence of the S antigen from 
the patient s red cells is deduced only from the presence of anti S In her serum 


evidence that the patient had ever had a blood transfusion ^ 
and in view of the raised activity of the antibody at lower 
temperatures it is probable that this patients anti S differs 
from eight of the nine other known examples in being of 
natural occurrence Although the paUcnt was Rh negative 
(cde/cde) the anti S was not accompanied by anti D Since 
D IS a very much stronger immunizing antigen than S and 
since five examples are known of anti-S accompanied by 
anti D or some other Rh antibodies the absence of anti D 
in this case is further evidence that the anti S is not a 
product of some immunization which does not appear in 
the history of the case It can be deduced from the diagram 
that in one at least of her pregnancies the patient was 
exposed to the risk of immunization to the D antigen, 
and in view of her husband s Rh genotype she must 
have been exposed in ali her pregnancies to the possibility 
of immunization to either C or D if not both 

In spite of the probable spontaneous origin of the anti S 
and of its apparent lack of relation to the clinical condition 
it IS probable that if transfusion bad been attempted without 
the very careful cross matching which was done a reaction 
would have occurred 

It may be noted that the other two antibodies associated 
With the MNS system- — namely anti M and anti N — both 
occur as ranties in human serum, and that m each case 
some of the examples seem to be of spontaneous and some 
of immune origin 


At necropsy the body was that of a very obese woman 
With generalized oedema and fluid in all cavities Large 
vegetations were found on the mitral valve with old and 
recent infarcts in the spleen and kidneys The latter were 
small and death was ascribed to endocarditis and chronic 
nephritis 

The patients serum had unfortunately not undergone a 
Wassermann test during her last illness or immediatety after 
death When a specimen was tested more than a year after 
death the result was equivocal No evidence of syphilis had 
been found on post mortem examination The husband s 
Wassermann reaction was negative 


Genetics 

The pedigree shown m the diagram does not account for 
the presence of anti S in the patient s serum since neither 
her surviving child nor any child by her husband could 
have been S positive and so immunized her to the S antigen _ 
The fact that she was MN and made anti S shows that her 
genotype was MsNs Since among her brothers and sisters 
all the four combinations MS+, MS- MNS+ and MNS- 
were found the genotypes of all of them can be deduced 
as well as those of their parents The genotypes of MS- and 
MNS- are bound to be MsMs and MsNs rcspeUively Since 
homozygous MsMs is present m the children each parent 



Jan 20 1951 


AGGLUTININ ANTI S IN HUMAN SERUM 


BunsH 

Moical Jouhsal 


Ml 


must have had an Ms chromosome and the one who sup 
plied the Ns chromosome to the children must ha\e been 
MsNs To account for the MS+ child the other parent 
must have been MSMs Thus the genoi> pes of the S positive 
children must be MSMs and MSNs respectively The 
patients husband is MsMs and their son who is MsNs 
got Ms from his father and Ns from his mother 
This family does not open up any possibilities of detect 
mg cross overs between the MN and Ss loci but 123 families 
have now been investigated without the detection of a cross 
over (Race Sanger Lawler and Berlinshaw 1949) This 
fact and even more strongly the maintenance in the general 
population of an uneven distribution of S and s with respect 
to M and N show that crossovers must be very rare and 
the linkage between the loci must be comparable m close 
ness to that between the C D and E loci on the Rh chromo 
some When it was found that the antibody was probably 
of spontaneous ongin it was thought that its occurrence 
might be genetically determined The sera of the patient s 
three S negative siblings were therefore examined for anti S 
but none was found 


Summon 

A summary of previous work on the occurrence of anti S 
in human serum is given Eight of the nine known examples 
other than the present one appear to be the results of 
immunization and seven of them contain some form of 
anti Rh 

A case is described in which anti S seems to have occurred 
spontaneously and was discovered in a direct matching test 
in preparation for a transfusion The serum from this case 
has proved to be a valuable testing reagent for the S factor 

Addendum 

While this paper was in the press the serum from a fatal 
transfusion reaction case was referred to the M R C Blood 
Group Reference Laboratory it was confirmed that it 
contained anli S and no other abnormal antibody 


References 

Callender S T and Race, R R (19461 ^rrn Eugfn 13 102 
Collins J O Saticer Ruth Allen F H lun and Race R R 
(19^0) British MfdicaJ Journal 1 1297 
Culbush Mane and Mollison P L (1949) Lancet 1 102 
Mollison P L (1950) Blood Transfusion m Clinical Medicine 
Blackwell Sacniuic Publicauons Oxford 
Pickles M M (19-8) I\aturc Lend 162 66 
Race R R Holt H A Gnnus J and Bessis M (1949) C R 
Soc Biol Pans 143 980 

and Smper Rmh (1950) B^ood Groups m Man Blackwell 

Scientific Publications Oxford 

Lawler S D and Berunshxw D (1949) Heredity 3 

205 

Sanger Ruth and R-cc R R (1947) Haliire Loud 160 505 
Walsh R- j and Monigomcry C (1948) Heredity 

\\als^ R and MonlEomcry C M (1947) Nature Land 
160 504 


The Hampstead Health Institute wh ch the London 
Count) Council is considering acquinne for conxersion into 
a health centre under the National Health Service is a large 
22 roomed house in an overcrowded district of Kilbum It 
was founded in 1911 b\ the laic Mr Thomas Hancock Nunn 
and is supported "b) pnvaic subscription and b) the rent 
received from certain subtenants It runs two social clubs and 
an old peoples club and dances are occasional!) held and 
in addition it houses the local Citizens Advice Bureau Poor 
Mans Law) cr S^AFA andHSA branch offices and the 
Hampstead Asso'-ntion for Moral WcTare Work An LC C 
maternitv and child welfare clinic is open four full davs a 
week Dental aural and ophlhalm c clinics are held rtcu 
lari) and classes for brcalhinc exercises and for squint 
meet once a week The Minor Ailments Centre of the 
Institute IS open every da) with a doctor present cverv 
Wednesdav 


THE EFFECTS OF HEXAMETHONIUM 
BROmOE ON THE STOMACH 

BY 

A. H. DOUTHWAITE, MD, FRCP 

Physician Guys Hospital 
AND 

M G THORNE, MD, MR CP 

Medical Registrar Guys Hospital 

The following is an account of a study of the action 
of hexamethonium bromide (C6) on gastnc secretion 
and motility which was undertaken in the light of a 
paper by Kay and Smith (1950) Working with patients 
suffering from duodenal ulcer, they found that a closely 
similar compound, hexamethonium iodide inhibited the 
spontaneous secreUon of hydrochloric acid to the point 
of achlorhydria They also showed that the compound 
mhibited the secretion of acid which normally occurs 
m insulin induced hypoglycaemia but did not affect that 
produced by histamine They noted too that the drug 
induced a prolonged inhibition of gastric molilil> 

For the purposes of our investigation it was decided to 
use two routine and commonly practised tests — the 
barium meal and the gruel test meal These tests were 
chosen, first, because of the value for comparative pur- 
poses of assessing_ the properties of new compounds by 
previously tried methods secondly, because both these 
tests afforded an opportunity of studvmg the action of 
C6 on the full rather than the empty stomach, in contrast 
to the work of Kay and Smith , and lastly because most 
of the subjects employed were old cases who well knew 
the routine tests and in whom undue apprehension 
would therefore be avoided This was considered to 
be important as the marked inhibitory effects that strong 
emotions exert on gastric motility should be eliminated 
so far ps possible 


Effect on Gastnc Motility \ 

Ten patients were chosen Nine were males with clmi 
cal and radiological evidence of duodenal ulcer and one 
was a female without such evidence their ages ranged 
from 16 to 56 years They were bed patients and 
some had previously been treated with Lhyoscy amine 
sulphate and alkaline powders but in no case were these 
drugs given within 12 hours of the tests On the day 
before the trial a test dose of 50 mg. of C6 was given 
intramuscularly and the patient was observed in the 
supine and erect positions so that hvpcr reactors could 
be excluded from the subsequent experiments 
Gastnc motility and emptying time wc'e assessed 
radiologically by means of barium meals The patients 
having fasted for at least 12 hours were given about 
three quarters of a pint (426 ml ) of barium meal to 
swal'ovv They were screened during the actual swallow- 
ing of the meal kept under observation until it had 
entered the duodenum and subsequently rc-exammed 
radiologically m half an hour and if this was indicated 
thereafter at hourly intervals In the intervals between 
being screened the patients sat in chairs but the actual 
X rav films were taken with the subjects in the erect 
position unless they felt faint The points that were par 
ticularly noticed dunng the examination were gastric 
tone as revealed by the shape and perista sis of the 




112 Jan 20, 1951 


EFFECTS OF HEXAMETHONIUM ON THE STOMACH 


Barmn 

MojicalJournai 


r 

I 

1 



Fig 1 — Case 10 Control appearance oE the stomach immedi 
ately after the swallowing of a barium meal 

Stomach, and emptying time, as shown by the measure- 
ment of the interval before the first appearance of the 
meal in the duodenum and the appearance of the stomach 
in the half hour and subsequen* films 
All the subjects were first given control barium meals, 
and nine out of the ten were shown to have highly 
motile stomachs with active peristalsis and a consequent 
rapid appearance of barium in the duodenum (see Table) 



f-io 2 — Ca:>c 10 Coni ol half an hour after the banum 
meal showme almon complete gasinc emptying the meal bcmg 
distnbuted tlmoughoul the jejunum 


Time Intervals Between the Taking of a Barium Meal and its 
Observed Entry into the Duodenum 


Case No 

Control 

ce 

2 

4 minutes 

10 minutes 

4 

Immediate 

10 

5 

4 minutes 

5 

8 

Immediate 

20 ^ 

9 


30 

1 3 6 7 10 

/Differences between control and C6 too small 

\ for assessment 


The timing is approximate only because of the impracticability of keeping 
the subjects under continuous screening 


After half an hour nine of the ten stomachs had emptied 
themselves of about four fifths or more of their con 
tents, the tenth being half emptied, and the banum was 
distributed throughout the jejunum, having traversed 
the duodenum, leaving it nearly void of radio opaque 
material (Figs 1 and 2) 

Three days later seven of the subjects were given 
100 mg of C6 intramuscularly half an hour before 
receiving a barium meal No obvious difference was 
noted in the shape of the stomachs immediately after 
takmg the meal , but there was some diminution in 
penstalsis, which was by no means completely inhibited, 
however (Fig 3) In five cases there was, too, a notable 
prolongation of the interval between the taking of the 
banum and its apparent entry into the duodenum (see 
Table) 

The half-hour films differed remarkably from the con 
trols In no case had the stomach emptied itself of 
more than about a quarter of its contents The por 
tion of the meal that had passed through the sphincter 
was almost completely confined to the duodenum and 
the beginning of the jejunum, which on screening 
appeared as immobile dilated segments of bowel, so 
loaded with barium that the. normal mucosal pattern 
was obliterated (Figs 4, 5, and 6) Subsequent x ray 
films revealed that this state of affairs persisted for 
varymg periods of up to s« hours 

Seven of the subjects were given repeated doses of 
100 mg of C6 four times daily at four hourly intervals 
for a period of seven days, after which the barium meal 
was repeated All seven reacted in a manner similar to 
that already described But a close study of the films of 





Fig 3 — Case 10 100 mg of C6 given half houi him show 

mg delaied gastne empiymg and the confinement of banum 
to the first and second parts of the duodenum Although there 
IS delay m emptying gastne penstalsis is present 






Jav 20 1951 


EFFECTS OF HEXAMETH.ONTUM ON THE STOMACH 


Elxrnsn 

^!cnICAL JOITLNAL 


113 


this senes revealed that in four cases the inhibitorj 
effect was not so marked as it had been after the initial 
experimental dose, though in onl> one subject was this 
difference notable 

Effect of C6 on Gastric Secretion 

In this investigation routine gruel test meals were given 
as controls to patients who had fasted 12 hours or more , 
and three days later these tt ts were repeated half an 
hour after the administration of 100 mg of C6 intra 
muscularly The test was performed on seven subjects 
suffering from duodenal ulcer Six of these had high 
climbing acid curses which were only slightly lowered 
after the administration of C6 (Fig 7) In only one 
subject was the C6 followed by achlorhydria, and here 
the control meal had shown a low acid curse initially 
(Fig 8) Emptying times were found to be slightly 
prolonged but these results were not comparable to 
those obtained svith the barium meals and were assessed 
less accurately 

Side-effects of C6 

The most disabling side effects ssere those consequent 
upon a loss in vascular tone Of the ten subjects six 
fainted while standing erect drinking their barium meals 
and the others felt faint These sensations xvere reheved 
when the patient sat down or when the x ray table was 
tilted to an angle of about 30 degrees to the horizontal 
In addition three patients were rejected from the trial 
because of their vigorous reaction to a 50 mg test dose 
The onset of syncope was associated with a weakening 
and sometimes complete obliteration of the radial pulse, 
and was aceompanied by tachycardia 



Fig *5 — 9 Conirol half houF film, «howan£ grcaicr pan 
of meal m small mteslmc 



I 


Fig 5 — Case 9 lOJ mg of C6 half hour film Note the 
retention of barium in stomach and duodenum 

Comparatiae readings of the blood pressures of eight 
patients were taken in supine and erect positions, with 
and without C6 In no case was there significant altera 
tion of the supine blood pressure when this was taken 
three quarters of an hour after a single injection of 
100 mg of C6 But in all cases in which an attempt was 
made to estimate the blood pressure in the erect position 
syncope ensued or threatened to ensue 

All the patients noted transitory defects of visual 
accommodation, and six felt dryness of the mouth 
developing about 20 minutes after the administration of 
C6 in addition four complained of a burning sensa- 
tion in the eyes Those patients who were in a position 



Fio 6— Case 9 S^ae as m Fig. 5 tuo hours later Th- meal 
IS held baeJ: in Ihc duodenum and j-junum 





114 Jan 20, 1951 


EFFECTS OF HEXAMETHONIUM ON THE STOMACH 


Brittot 

Medical Journal 


to make the comparison agreed that visual symptoms 
and dryness of the mouth were not so pronounced 
as when they had been taking l hyoscyamine sulphate 



HOURS 


F'O 7 — Average test meal values o£ seven patients with and With 
out C6 Case 7 (Fig 8) was not included in this senes 



> • I I 1 1 1 r 

'A Vi % I I'A I'A PA 2 
HOURS 


Fig 8 — Case 7 Gruel test meal 
curves with and without C6 demonstnt 
ing the production of achlorhydria This 
was the only case in the scries showing 
such an effect 


or belladonna Of 
those who were 
treated with C6 
tor a week two 
complained of oc 
casional abdomi 
nal discomfort 
and nausea This 
discomfort took 
the form of a 
bloated sensation 
and anorexia 


In general all the other side reactions became less 
marked towards the end of the course of treatment, 
though standing still in the erect position, as for the 
estimation of blood pressure or for screening, still caused 
famtness 


Discaision 


Kay and Smith found complete inhibition of peristalsis 
for periods of up to four hours They were, however, 
studying the empty stomach and not, as here, the loaded 
one , and this may explain also the fact that we found 
the free and total gastric acid levels httle altered, while 
they noted a marked lowering of free acid in the resting 
stomach and a modified response to insulin but not to 
histamine It may be that we were primardy measuring 
hormonal rather than vagal induced acid secretion, and 
that the exact effect of C6 depends on the extent to 
which the vagal factor is involved in the total secretory 
response to gruel in any particular case Their results 
show that C6 might be beneficial in suppressing spon- 
taneous gastric secretion 

There are however, the following possible drawbacks 
to Its therapeutic use First, m all the subjects of our 
experiments vasomotor side-effects of the drug when 
given in doses of 100 mg intramuscularly were incapa 
citating enough to make it unsuitable tor ambulant 
patients Secondly after continued use C6 might lose 
some of Its potency as an agent which inhibits gastnc 
and intestinal motility Finally the effect on a duodenal 
ulcer of an artificial duodenal ileus produced by C6 
cannot be predicted with certainty for whtle diminished 
peristalsis and relaxation of the bowel wall might well 
have a beneficial effect distension of the duodenum 
would probably be harmful The dangers of an associa 
tion of duodenal ileus with ulcer were pointed out by 
Hurst Rowlands Jones and Ryle (1926) who described 


two such ulcers which perforated and three others which 
remained resistant to medical treatment 
Although the ileus artificially induced by C6 lacks the 
organic obstructive element of the naturally occurnng 
condition, it is difficult to be certain that the barium 
meal arrested by C6 in the upper part of the jejunum is 
not Itself acting as an obstruction Measurements of 
mtraduodenal pressure should decide this pomt. 

In general the disadvantages of C6 discussed above 
come into operation only when the subject is ambulant 
and taking food , thus its potentialities would seem to 
be strongest for bed patients and for use at night 
The experiments were not in the nature of a thera 
pcutic trial, all the patients being without symptoms at 
the time of the tests, and receiving orthodox treatment 

Summary 

C6 given in doses of 100 mg intramuscularly to 10 
patients was found to delay the onset of gastnc empty 
mg of a barium meal for periods of up to 30 minutes and 
completion of emptying till the sixth hour 
Gastric peristalsis was dimmished but not completely 
inhibited, and there was Ob' change in the shape of the 
stomach The small gut (particularly- the duodenum and 
upper jejunum) was revealed to be dilated and immobile 
for periods of up to six hours after the drug was given 
Gastric secretion as revealed by the gruel test meal was 
only slightly altered by C6 The patients in this tnal were 
found to be much more susceptible to the unpleasant side 
effects of the drug than those reported fay Kay and Smith 
perhaps because they were bed pauents 
The properties which C6 possesses suggest that the drug 
may be of therapeutic value m the treatment of gastnc and 
duodenal ulcer particularly in bed patients and at night. 

We acknowledge with thanks the helpful co-ojieration of 
Dr T H Hills director of the Department of Diagnostic 
Radiology Guy s Hospital and his colleagues We express our 
thanks also to Messrs May & Balccr Lid for the supplies of 
hcxamethcmium 

References 

Hurst A F Rowlands R P , Jones J G and Ryle J A 
(1926) Cu) s Hasp Jiep 76 162 , 

Kay A W and Smith A N (1950) British Medical Journal 
1 460 


At a meeting of the Zoological Soaety of London on 
December 12 last Dr L Harrison Matthews showed slides 
and a film to illustrate the account of an expedition to the 
island of Ramsey to study the process of lactation in tlie 
grey seal during September and October 1950 An adult 
female seal was captured by means of a special net, and was 
kept in captivity with her baby tor fifteen days Daily 
weighings of mother and young were made specimens of 
milk were taken for analysis and information on the 
breeding and nursing habits of the seals was collected The 
average daily gam in weight of the pup was 3 3 Ib the 
weight increasing from 43 lb on the third day after birth 
to 92 Ib on the eighteenth (the birth weight of the grey seal 
IS about 30 lb ) The average daily loss in weight of the 
mother was 6 3 Ib during the same period her weight 
decreasing from 371 Ib to 276 Ib a total loss of 95 lb 
Adult and pup occasionally drank small amounts (undeter 
mined) of water both fresh and salt but the mother did not 
feed dunng the nursing period Dailv weighings of a number 
of pups at liberty showed that the growth rate of the captive 
pup was nol affected by the conditions of captivity Analysts 
of the milk (undertaken by Dr I R Rowland) showed over 
67% solids with over 53% fats The captive pup was weaned 
on the eighteenth day after birth and left the beach on the 
thirtieth after it had completed the moult of its natal coat 
Both adult and pup were surprisingly docile m captivity 





Jav 20 1951 . ADDISONS DISEASE OCCURRING IN TWO BROTHERS 


DxirKH 

NtiDICAL Jol.Il.NAL 


115 


Not only is the number of reported cases small but 
ADDISON’S DISEASE OCCURRING IN m most of them the esidence does not satisfy the modern 


TWO BROTHERS 

BV 

J N BRIGGS, MD, MR CP 
J r GOODWIN, MD, MRCP* 

AND 

A. WILSON, MD, PhD, FRTPSt 

tr rom the Department of Phnrinacolos\ and Tlicrapeiittcs 
Unit ersit} of Sheffield the Sht ffield Children s Hospital 
and the Sheffield Iio\al Infirmary) 

There are two aspects of Addison s disease on which 
relatively little information is available one is its 
occurrence in childhood (m all about 60 cases have 
been reported) and the other concerns the role of 
hereditary factors 

It has periodically been suggested, especially when 
this disease has occurred in several members of the 
same family that the condition may be inherited This 
hypothesis is perhaps plausible since there is evidence 
that hereditary factors operate in other endocrine 
disorders — for example diabetes mcliitus and the 
Laurence-Moon-Bicdl syndrome In studying any such 
relationships the two important features necessary arc 
reliable criteria of diagnosis and an adequate supply 
of clinical cases 

Addison s disease is a relatively rare condition never 
thcless several possible familial cases have been 
recorded Fleming and Miller (1900) described a mother 
who was quite well until her first pregnancy when she 
became pigmented and asthenic Her condition showed 
an exacerbation after each succeeding pregnancy One 
child died at birth and the four remaining children 
whose ages ranged from 2} to 7 years were all pig 
mented and suffered from unexplained attacks of diar 
rhoea and vomiting Unfortunately there was no 
follow up or necropsy Groom (1909) described three 
sisters who were pigmented and asthenic, but there 
IS insutlicicnt biochemical evidence and there was no 
follow up or necropsy in any of his three cases Wake 
field and Smith (1927) presented the case of a man 
aged 2S in whom necropsv revealed absence of the 
riaht suprarenal Two of the man s brothers his father, 
grandfather and a paternal uncle were all pigmented, 
while seven other brothers were fair skinned but there 
was no chmeal examination or follow up in any of these 
relativ cs 

In discussing Addisons disease in relation to heredity 
Morabilo (1927) has drawn attention to a case in which 
a brother and sister aged 7 and 10 vears rcspcc 
tivclv became graduallv pigmented and in whom the 
Von Pirqiet test was strongly positive In both parents 
and children the Was'ermann reaction was positive He 
attributed the pathology to congenital syphilis with 
superadded tuberculosis Borghini (1937) reported the 
case of a Hvearold Italian boy who was under 
nounshed and subject to attacls of weakness on slight 
exertion Tlie bov s mother apparentlv had died from 
tvpical Addisons disease but after a five v car follow 
up the child s general condition was unaltered and there 
was no change in the pigmentation 

Now nt ihe ro^pniiJL-te Medical School H ”'n'»rsnilh 
Lerdon 

+Now M Vnj\-cr^f' College Ho^ a! Mcdi'al School Lo’“don 


criteria for the diagnosis of Addisons disease In his 
c\tensi\c revievN of 566 reported cases Guliman (1930), 
although doubtful whether heredit) pla>s an important 
part in the genesis of the disease states that it can 
not be dented that in rare instances there is a hcrcdilar> 
tendency 

In Mcw of the relative paucity of information on 
this aspect of the subject it is important, now that 
reliable diagnostic methods arc available, to investigate 
thoroughly all cases in which the disease occurs in more 
than one member of a family We have rcccntl> 
observed two young brothers with Addisons disease 
whose case reports follow 

Case 1 

A schoolboy aged 12 was ndmitted to the Sheffield 
Childrens Hospital on July 30 1946 complaining of 

lisllcssness anorexia loss of weight vomiting and 
diarrhoea which had gradually incfcascd during the 
previous three weeks The symptoms were nt first 
asenbed by his doctor to an attack of gastro enteritis 
but as there was no response to treatment the child was 
referred to hospital His mother stated that since infancy 
the boy had been very fond of salt and would often eat 
this alone He had had measles chicken pox whooping 
cough and mumps There was no family hisiorv of 
tuberculosis abnormal pigmentation or Addisons disease 
Apart from his brother there were no siblings 

On admission the patient was very drowsy had inter 
miitcnt attacks of retching and diarrhoea and responded 
to questioning with difficulty He was markedly dehydrated 
There was diffuse dark brown pigmentation of the face 
back of the neck dorsum of the hands the forearms and 
the extensor surfaces of the legs extending from the knees 
to the ankles The buccal mucous membrane was not 
pigmented 

The apex beat was not palpable and by percussion the 
heart was H (3 75 cm) internal to llie mid clavicular 
line The heart sounds were faint and regular no mur 
murs were heard The pulse rate was 120 a minute weak 
but regular and the blood pressure was 80/40 There were 
no abnormal features in the abdomen lungs or nervous 
svMcm and no cosio lumbar tenderness He was of normal 
stature but both testicles were undescended and 4he penis 
was underdeveloped Apart from three carious teeth there 
was no ojhcr evidence of any local infection 

The unne showed no albumin or sugar ketones were 
present there was no deposit examination of the blood 
showed rSR 16 mm in one hour fasting blood sugar 
50 me per 100 ml plasma potassium 2^ mg per 100 ml 
scrum sodium 280 mg per 100 ml Robinson Power and 
Kepler (1941) excretion test ratio A = 4^ haemoclobin 
l(K)'* red cells 5 010 000 white cells 9 400 (neutrophil 
polymorphs 6S monocytes 4% basophils I'i lympho 
cytes 27 J^) Radiographs of the chest showed a small heart 
shadow and normal lung fields (Tic I) The elcctrocardio 
gram revealed sinus tachvcardia and low voltage curves 
with S-T depression and flat T waves in all leads Radio 
graphs of the abdomen showed two calcified glands in Ihe 
region of ihc ncht iliac fossa The Mantoux test with 
1/1 000 old tuberculin was positive 

Immediatelv on completion of the invcstications adrenal 
cortex extract ( cucortonc was given in 10 ml doses inlra 
muscularU cverv six hours and DC A 5 mg every 12 
hours Tlie following day supplementary salt (4 g six 
limes a dav) was civcn and he drank fluids caccriv By 
Aucust 5 there was a striking clinical improvcmcrt He 
was alert and answered questions quicklv and accur-’lely 
He ate his food caccrU and took an active interest in his 
surroundincs The apex beat was now palpable ard the 
pearussion note indicated an increase in cardiac dullness 



116 Jan 20, 1951 


ADDISONS DISEASE OCCUR.R1NG IN TWO BROTHERS 


British 

MsDICAI JOlKSAL 


to the left The blood pressure was 100/74 and radio 
graphs of the chest revealed a marked increase in the heart 
shadow (Fig 2) The electrocardiogram was normal 
On August 8 pigmentation was less diffuse and dark areas 
were still apparent on the flexor surfaees of the forearms 
and hands, along the vertebral column and anterior superior 




pio 2 — Case t Chest radiograph after treatment The heart is 
now normal in size 


iliac spines and on the abdomen at the level of the trouser 
belt There was no evidence of buccal pigmentation Blood 
pressure was 100/75 On August 10 adrenal cortical extract 
was discontinued and DC A reduced to 2 5 mg every 48 
hours Supplementary salt therapy was continued The 
next day he was able to walk unaided m the \/ard and his 
general clinical improvement was maintained On August 19 
the second Robinson-Power-Kepler test showed a value of 
19 His blood pressure remained stationary at 102/72 and 
he gradually increased in weight On August 30 a 25 mg 
pellet of D C A was implanted by Mr Clifford Jones on 
the right rectus sheath under local analgesia Two days 
later intramuscular injections of D C A were discontinued 
At this time the serum sodium was 315 mg per 100 ml 
plasma potassium 21 mg per lOO ml and the Robinson 
Power-Kcpler excretion test ratio A=25 

He was discharged and referred for follow up as an out 
patient He required a second implantation after three 
months, and was then given 150 mg of DC A He has 
had two further pellets of 150 mg of DC A the effects 
of each lasted approximately seven months With this treat 
ment he has for two years been adequately controlled and 
IS able to attend school regularly and to walk distances up 
to two miles without excessive fatigue His pigmentation 
has increased m intensity and small areas are now preseni 
on the soft palate His blood pressure remains at about 
100/55 mm Hg 

The 24 hourly unnary output of 17 ketosteroids was 
5 mg and in view of his cryptorchidism chorionic 
gonadotropin ( gonan ) was given intramuscularly, 500 
1 U twice weekly for six weeks His penis increased in 
size and six months hler both testicles were descended 

Case 2 

The elder brother of Case 1 aged 17 was admitted to 
the Royal Infirmary, Sheflield on July 31, 1947 He had 
been in good health until five weeks before admission when 
he complained of epigastric pain and vomiting which lasted 
24 hours One weel later he had a recurrence of the pain 
while suffering from a septic great toe nail This was 
removed by his own practitioner, but he had two further 
attacks of abdominal pain and vomiting the second attack 
leading to his admission to hospital Pigmentation of skin 
and loss of weight had been noticed recently There was 
no relevant past history 

He was a veil developed youth with very faint generalized 
pigmentation and a small area of pigmentation on the 
buccal mucosa T here was slight dehydration The cardio 
vascular svstem was normal BP 120/70, pulse 104 regular 
Respiratory abdominal and central nervous systems were 
normal His temperature was 97 F (36 1 C) A trice 
of albumin was found in the urine Examination of the 
blood showed E S R , 12 mm in one hour serum sodium 
345 mg per 100 ml serum potassium 17 mg per 100 ml 
NPN 60 mg per 100 ml Hb 103% red cells 5 250 000 
white cells 5400 (polymorphs 53%, lymphocytes An 
monocytes 3%) 

A tentative di ignosis of Addison s disease was made, and 
the patient was given liberal fluids and extra salt by mouth 
This did not stop the vomiting so an intravenous infusion 
of sodium chloride and 5% dextrose was set up 
hours later he suddenly became extremely restless and the 
pulse rose to 140 a minute There were no signs of pul 
monary oedema and no abnormal signs in the central 
nervous system The restlessness continued and the next 
morning his condition had deteriorated well marked neck 
rigidity and pyrexia had developed A lumbar puncture 
showed a normal pressure and no block The fluid ivas 
clear and normal His blood pressure was 125/65 

In spite of continuous therapy with adrenal cortical 
extract penicillin and intravenous glucose saline the 
patient diad 72 hours after admission His pigmentation 
had increased markedly during the last three days of his 
life but the blood pressure remained normal until three 
hours before death when the systolic pressure fell to 70 


Jan 20 \95\ ADDISON S DISEASE OCCURRING IN TAVO BROTHERS 


A postmortem examination Nsas mide b> Dr L C D 
Hermitlc Both suprarenal glands ucrc atrophic and histo 
locicd examination showed simple atroph> invol\ing maml> 
the cortex (Fig 3) The ih>mus was considcrablj larger 

than normal and 
the thyroid gland 
was also enlarged 
the gonads and 
pituitary body 
were normal The 
Iicart was small 
and the lungs 
were slightly 
oedematous the 
right lung having 
SIX lobes and the 
left lung four 
There were no 
other important 
findings 

It IS difficult to 
account for the 
sudden detenora 
1 1 o n in this 
patient s condi 
tion and his failure 
to respond to treat 
ment* It IS possible 
that the maintc 
nance of a normal 
blood pressure till 
the terminal stages 
of his illness was 
due to the rela 
live integrity of the 
mcduilae of the 
suprarenal glands The enlarged th>mus gland directs 
attention to the possibilil) of m> asthenia gravis but there 
was not at an> lime clinical evidence of this disease The 
congenital abnormalil> in the lungs is noteworth) 

Discussion 

Because these two cases of Addison s disease occurred 
in brothers their famil> histor> was carefully and 
e\hausincl> investigated Both parents were health^ 
Thc> came from a large cit> and their families were 
not m an> way related Tlicy had only the two children 
The maternal grandparents died in old age and their 
children were not pigmented though one son had a 
wasting disease in childhood but recovered and was 
lost at sea in the second world war No relevant infor 
mation vvis available regarding the paternal grano 
parents other than that the grandmother died at the 
ace of 82 and that the grandfather is still alive and 
well aged 7^ There arc several paternal cousins who 
have not been traced but who at least until adult life 
arc known to have been hcalthv 

\Vc are of the op nton that in each patient the disease 
was due pnmarilv to atrophv of the suprarenal glands 
It IS not surprising that the voungcr brother had calcified 
abdominal glands since he nad been tal mg farm milk 
which was neither pasi-'iinzcd nor boiled 

Tlic occurrence of such a rare d scasc in two brothers 
and at an carlv age sucgesls the possibililv that a 
ccncl c factor mav be involved 

Summarv 

Tlic h -n lire rc’atinc ;o po« bdiiv cf a familial 
factor n addj^on^ di^c-'^e his been rev -“v ed The 
oxiirrc''ce cf AdJivcn < di<- a'^e m tv^o bro b-r*; is d-«c*ab^ 
In ^e pilie^t who d cd atrophic supraren! c'ands a-'J 
congenjlil abnormi! ics of tbe ’uncs v e-e found at 


necropsy The cause of ihc disease in (lie two cases pre 
scntcd IS considered to be primary suprarenal atrorh> In 
view of the sugccstivc but inconclusive evidence afforded 
bv this and other cases reported vse consider that the 
familial and genetic aspects of Addison s disease merit 
further study 

We wish to thank Professor E J Wavtie for permission to 
publish thc-c cases and we are grateful to Dr L C D Hcrmiltc 
for his report on the necropsy findings in Case 2 

Reftrences 

Borghini G (1937) G Clin ined 18 43S 
Crooni D 11 (1909) Lancet 1 603 

I leming R A and Miller J (1900) British Mcdicnl Journal 
1 1014 

Guttman P H (1930) Arch Path 10 742, 

Morabito F (1927) Pedtatria 35 969 

Robinson F J Powxr M H, and Kepler E J (1941) Proc 
Mayo Clin 16 577 

W'akcficid E G and Smith E F (1927) Aruer J wr t Si 
174 343 


THE ELUORESCCNCC PHENOMENON OF 
THE TONGUE 

BY 

\V TOMASZnVSM, M D Pornan, PhD 

(From the Department of Therapeutics Clinical Lahorainr\ 
Roittt Iiifirtnary Cdinhiirgh) 

When the mouth is \ievsed under ultra violet light 
screened with Woods glass a reddish orange (luor 
csccncc IS often \isiblc on the dorsum of Ihc longue 
and sometimes on the teeth This fluorescence has 
been recognized for some time and has been proved 
to be due to the production of porphyrins by oral 
micro organisms So far however, this fluorescence 
has not been adequately studied m relation to the 
various changes m the tongue that arc known to result 
from nutritional deficiencies 

Several authors have described this phenomenon 
Derrien (1924) noticed fluorescent points in dental 
cavities which he attributed to decomposition of 
haemoglobin by bacteria The fluorescence of the 
carious teeth or of tartar must be distinguished from 
that of health) teeth in eases of congenital porphjrn 
as first described bv Mackey and Garrod (1925-6) 
Hvmans van den Bergh (192Sa 1928b) described this 
lluorc'cencc of the tongue in greater dclail and 
endeavoured to explain its aetiology but he did not 
study Its clinical significance More recently Costello 
and Luttenberger (1944) attributed the ab'cncc of the 
normal fluorescence to vitamin B deficiency Accord 
ing to them it is intense in children but Ics marked 
m well nourished adults 

Hagerman and Hirschfeld (1947) e'amin'd over 5'K) 
patients in a dermatological clinic In about 60% of 
their patients the fluorescence extended over the whole 
tongue or covered about half of the dorsum which 
was considered to be normal About every fourth 
patient showed fluorescence over the whole surface 
Toniucs showing absent or very limited fiuorcsccncc 
were regarded as abnormal These authors found that 
patients showing absent or grcallv diminished fluoi 
cscencc often suffered from the si in lesions usuahy 
associated with vitamin B dcfiacncv Thev noticed 
also that vitamin B p'cparations csp'cially those con 
taming panto heme acid u uallv produced a change to 
Ihc normal fluorescence (Bnrish Mce'ical Journal f9-,9; 




118 Jan 20 1951 


FLUORESCENCE PHENOMENON OF THE TONGUE 


Ewnsa 

5feDICAL JoURNAi 


Red fluorescence due to porphyrin is encountered in 
other parts of the human body, both in health and 
in disease It has been seen in sebaceous comedones 
(Bommer, 1927, 1929) as bright-red points on the nose, 
around the lips, etc Red fluorescence is often present 
in the menstrual and lochial discharges (Jones, Figge, 
and Hundley, 1944) probably due to porphvnn pro 
duced by bacterial decomposition of blood It usually 
disappears a few days after menstruation The tumour 
chloroma contains an excessively large amount of 
porphyrin (Thomas and Bigwood, 1935) Necrotic 
tumours (Pohcard 1924) and many necrotic non 
malignant tissues also exhibit red fluorescence 

Method 

Over 400 patients in medical wards and in the 
blood clinic of the Edinburgh Royal Infirmary were 
examined for fluorescence of the surface of the tongue 
and teeth An ordinary ultra violet lamp with Wood s 
glass was used 

Diseases characterized by changes in the tongue were 
specially selected, and, for comparison, examinations 
were' also made in various other diseases and m a 
number of healthy people of different ages In each 
case a rough sketch of the surface of the tongue was 
made Besides ordinary data concerning age, sex, 
disease, etc , a short nutritional history was taken 

In some cases antibiotics, vitamins, and chemothera- 
peutic agSnts were given in order to investigate the 
influence of these substances on the fluorescence 

Appearance of the Tongue under Ultrn-nolet Light 

The majority of healthy persons show fluorescence on 
the. posterior half or three-quarters of the tongue s sur- 
face The rest of the surface, especially the anterior 
part, often has a greyish or whitish tinge Only about 
20% of healthy persons exhibit fluorescence on the 
whole tongue The margins and the tip are as a rule 
free The fluorescence has usually a red or orange hue 
but It often has a pinkish or yellow tinge Its intensity 
\aries considerably m different persons 

Observed through a magnifying glass, the fluor- 
escence, which to the naked eye seems to be 
coalescent, is seen to be composed of small fluor- 
escing points corresponding to the filiform papillae 
The material scraped from such a tongue is com 
posed of bacteria epithelial cells, and particles of 
food and on naked eye observation under ultra violet 
light shows a pinkish or red fluorescence 

Slightly coated tongues usually have a faint pinkish 
fluorescence Intense red fluorescence is often associ 
ated with a thick coating Tongues which do not exhibit 
red fluorescence have sometimes a quite normal appear 
ance under ordinary light 

In a few persons small non fluorescing lacunae are 
found on the red fluorescing area These lacunae have 
a tendency to enlarge eccentrically in the course of 
time In tongues with deep fissures red fluorescence 
can sometimes be noted 

It IS difficult to make an arbitrary distinction between 
normality and abnormality according to the extent of 
the area of fluorescence as has been attempted by 
Hagerman and Hirschfeld Our clinical material was 
divided simplv into cases m which fluorescence was 
entirely absent and those in which it was present even 
to a very slight extent The former vveie classified as 
negative the latter as positive 


Appearance in Healthy Individuals 

For control purposes over 200 healthy persons of 
both sexes and various ages vyere examined The 
examination of children was mainly carried out in the 
Princess Margaret Rose Orthopaedic Hospital Edm 
burgh Apart from their orthopaedic disabilities, the 
children were normal Subjects over 60 years of age 
were selected mostly from inmates of Queensberry 
House for the Aged, Edinburgh 

The climcal material was divided into age groups Of 
the total number examined, 59% were males and 41% 
females but as sex seemed to exert no obvious influence 
on the incidence of the fluorescence phenomenon males 
and females were considered jointly Their nutritional 
history did not reveal any evidence of deficiency The 
results are given in Table I which shows that absence of 
fluorescence increases steadily with age 


Table I — Fluorescence m Healthy Indt\ iduals 


Age Groiip 

■ Total I 
No 

I 

, Fluorescence of Tongue | 

1 7 

j Without 

4 - 

, - i 

0-20 years , 

71 1 

63 

8 

U 

21-40 * 

50 ] 

44 

6 ! 

12 

41-60 ' 

40 1 

33 

7 1 

I n 

61-80 

38 

28 

10 1 

26 

81-100 

15 1 

7 

8 

53 

Total 

214 

175 

39 

, IS 


In general, the intensity of the fluorescence in old 
people was definitely less than m children and younger 
adults There were often slight atrophic changes in the 
filiform papillae in old people, but even in apparently 
normal looking or coated tongues the fluorescence was 
often absent 

Fluorescence in Certain Diseases 

Special attention was paid to diseases wl^ich are 
associated with changes m the tongue 
Fermcioiis Anaemia — ^Altogether 87 cases of pemiciouv 
amemia were examined Most of these were well controlled 
cases that had been treated with liver some of them for 
many years or recently with vitamin B, Therefore most 
of them had normal or nearly normal haemoglobin levels 
Only six untreated eases were examined all showed com 
paratively low haemoglobin levels The results of the exam 
inations are given in Table II 


Table II —Fluorescence of the Tongue in Cases of Pernicious 
Anaemia 


Age 1 

j No of Cases 1 

No Without Fluorescence 

21-40 vea s 

i 

4 

41-60 j 

1 34 

18 

61-80 

1 47 

1 34 

Total j 

j 87 

1 56 (64/> 


Of the total number examined 64% were negative The 
fluorescence in (he positive cases was_ mostly faint Com 
pared according lo age groups the pernicious anaemia cases 
show a much higher incidence of negative cases than the 
normal persons Cases with a completely atrophic smooth 
tongue were all negative though some of them had 
haemoglobin values of over 100% ' 

It IS not known whether any fluorescence was present 
before ireatmeni in these cases Examination of the six 
untreated cases five of which were negative throws some 
light on this problem On treatment the somewhat atrophic 



Jan 20, 1951 


FLUORESCENCE PHENOMENON OF THE TONGUE 


Bxrmji 

MnjtCAL Joui!-*aL 


119 


tongues of four of them showed some grow-th of their short 
and atrophic papillae After a few weeks the surficc 
acquired a delicate whitish covering, and two of the patients 
previously entirely negative developed slight fluorescence 
It wems therefore that liver Iherapy can in some cases 
resi re the fluorescence but treatment of patients with 
adv ,nced atrophy of the tongue does not restore the filiform 
papi lae or the fluorescence The number of untreated eases 
w i however too small for any dogmatic conclusions to 
be drawn 

Hypochromic Iron dcficicnr, Anaemia — For. comparison 
a ^ up of patients suffering from iron deficiency anaemia 
of iiiTerent ongin but mostly nutntional were examined 
As well known this type of anaemia is often associated 
wii atrophic changes of the filiform papillae It is also 
kii *n that iron therapy frequently restores the condition to 
n I il Altogether 28 patients were examined— 22 women 
a 1 n men Their ages varied from 28 to 70 years the 
\ ge being 46 Of the 28 examined 17 (dO^o) were nega 
1 In general the pdsitive cases in this group showed a 
sti cer fluorescence than those in the group of cases suffer 
iiu 'rom pernicious anaemia In one negative case which 
w t observed before and after treatment restoration of 
p ; I ac and faint fluorescence followed improvement in the 
il loglobin level and in the general health but in cases 
wi permanently atrophic tongue the restoration of normal 
ha I oglobin values did not produce any fluorescence 

S ue Syndrome — Fifteen patients suffering from the 
spr le syndrome three being children with coeliac disease 
wen- examined The average age of this group was 33 
The majority showed an atrophic tongde or had soreness 
of the tongue they were all undergoing treatment Eleven 
patients (73%) were negative The four positive cases had 
been treated for several years with liver folic acid and 
other compounds of the vitamin B group In these four the 
tongue approached the normal in appearance and there was 
a slight fluorescence 

Other Diseases — Small groups of patients suffering from 
other diseases were also examined Castro intestinal diseases 
are often connected with lingual changes Out of 22 cases 
of gastric and duodenal ulcer with an average age of 43 
nearlv half showed absence of fluorescence On the other 
hand cases of gastritis with heavily coated tongues usually 
showed an orange or a peculiarly yellow fluorescence The 
results in a group of patients with an unusual appearance 
of the tongue are of some interest Three cases with hairy 
tongue were negative Seven cases with marked brown 
coloration of the coating of the tongue were all negative 
and in two the fluorescence appeared after a few days treat 
ment with nicoUnic acid Twelve cases of so<alIed scrotal 
tongue (lingua scrotahs lingua plicata) characterized bv 
numerous deep furrows were mainly negative In a group 
of seven cases which showed signs of vitamin B deficiency 
particularly of ariboflavinosis and characterized by angular 
stomatitis and red smooth tongues fluorescence was absent 
Groups of cases of diab'tes leukaemia and other diseases 
did not give any conclusive results 

Factors Influencing Fluorescence 

Observations were made on patients treated for 
various reasons walh antibiotics in order to study the 
effect of these drugs on the fluorescence of their tongues 
which was positive in cverv case before the beginning 
of treatment In addition a number of healths per- 
sons with sironglv (luorcscinc tongues were selected for 
investigation of the local action of penicillin and other 
antibiotics on the fluorescence 

Penicillin vvas given in 500-unit lozenges (8-10 a dav) 
to 5 persons After a few davs the fluo csccnce dis- 
-appeared complc civ m each case starting from the 
front and movang towards the back of the tongue In 


three persons a brown colour of the tongue appeared 
with some soreness of the dorsum With the cessation 
of penicillin treatment the red fluorescence reappeared 
gradually m a few days starting from the back of the 
tongue Penicillin given intramiiscularlv to four per 
sons 500 000 units daily for one week, did not abolish 
the red fluorescence 

Spcciallv prepared streptomvein lozenges (50 mg pci 
lozenge) were given to three persons in a dosage ol 
seven to eight lozenges a day for one week In all 
three the fluorescence disappeared in four to five 
days 

In five patients treated with chloramphenicol (2 g 
a day orally) for various diseases the fluorescence 
vanished rapidly and at the same time the normal 
coaling of the tongue disappeared Glossitis and signs 
closely resembling ariboflavinosis developed in two of 
them 

Specially prepared chloramphenicol lozenges (5 mg 
per lozenge) administered to three healthy persons in 
a dosage of 10 lozenges daily for a week brought about 
the disappearance of fluorescence in five to six days 

Similar results were obtained in three patients treated 
for various reasons with aureomycin, 2 g a day 
orally Trials were also made with aureomycin lozenges 
(5 mg per lozenge) on three healthy persons It vvas 
found impossible to evaluate the local action of aurco 
mvcm on the fluorescence during treatment as this sub 
stance itself produces a bright yellow fluorescence which 
covers the whole dorsum However with the cessation 
of the treatment the fluorescence which had prevaously 
been strongly positive, remained negative for two to 
three weeks 

In contradistinction to the cITcct of the antibiotics, 
the use of sulphathiazole lozenges six a day, seemed 
to have no cllect on the fluorescence phenomenon 

Observations were also made on the effect of folic 
acid riboflavin and nicotinamide on five patients with 
signs suggestive of vitamin B deficiency and with 
absence of fluorescence In three of them in whom 
definite regeneration of the papillae took place a slight 
fluorescence developed 

As has been mentioned reappearance of fluor 
csccnce was observed in some patients with pernicious 
anaemia after treatment with vitamin B,, and the same 
phenomenon was noted in cases of sprue syndrome 
treated with folic acid nboflavin and nicotinic acid 
and in cases of brown tongue treated with nicotinamide 

Pantothenic acid has some influence on the intensity 
of fluorescence In healthy persons with faint fluor 
csccnce treatment with pantothenic acid 50 mg three 
times dailv for two weeks, produced a marled increase 
in Its intensity 

Discassion 

There is no doubt that this fluorescence is due to the 
production of porphvrin bv penicillin sensitive micro- 
organisms We do not know whether the porphyrin is 
svaithesized bv the bacteria or whether it is the product 
of decomposition of haemoglobin derived from food 
or from the host Nor do we know the exact tvpe of 
bactenum (or bacteria) concerned in porphvrin p oduc 
tion in the mouth Carriif (1934) expressed the opinion 
that the normal fluorescence of the tongue and of 
comedones is due to a particular Gram positive bacil 
lus He claims to be able to cultivate this porphyrin 




120 Jan 20, 1951 FLUORESCENCE PHENOMENON OF THE TONGUE bmtob 

— Medical Joxdinai 


producing bacillus in special media— Sabouraud and 
Fmk media — but we have so far been unable to 
reproduce these results 

The actual role of porphyrin in the metabolism of 
the oral bacteria is also unknown Pappenheimer (1947) 
suggests that porphyrin, at least in the diphtheria bacil 
lus, might be produced in certain conditions in the pro 
cess of synthesis of some respiratory enzyme, probably 
cytochrome b 

From the clinical point of view it is of interest to 
inquire why this porphyrin production is absent in 
certain normal and pathological conditions, and what 
IS the part played by the vitamin-B group in its pro 
duction It seems that at least two factors are 
responsible for the fluorescence phenomenon (1) the 
presence of porphyrin-producing bacteria , and (2) the 
presence of normal papillae, since a smooth tongue 
does not, as a rule, exhibit fluorescence Judging from 
the fact that in a certain percentage of healthy and 
adequately nourished persons the normal looking tongue 
does not show fluorescence, some other factors must 
also be responsible We do not know why the percent- 
age of negative cases in healthy persons increases with 
age 

It IS doubtful whether the absence of fluorescence is 
of value as a clinical sign of vitamin B deficiency, as 
has been suggested by certain authors Some vitamin 
deficiencies, especially those of nicotinic acid, riboflavin, 
and aneurin do produce lesions of the tongue and 
raucous membranes In such cases where glossitis and 
atrophic papillae exist the absence of fluorescence is 
understandable There is, however, no proof that 
reduced or absent fluorescence is always due to 
deficiency of the vitamin-B complex 

Factors such as vitamin Bu, folic acid, vitamin-B 
complex, apd iron seem to have some influence on 
the restoration of fluorescence in certain conditions, 
doubtless duq to their action in regenerating the 
papillae In addition, the possibility that vitamins, as 
growth factors, have some action on the bacterial flora 
Itself cannot be excluded Mallinckrodt-Haupt (1938) 
reported a stimulating influence of vitamins notably 
aneurin and riboflavin, on porphyrin production by 
bacteria in \itro ' 

The pathological states here investigated — pernicious 
anaemia, sprue syndrome, and iron deficiency anaemia 
— are often associated with nutritional disturbances, and 
all are commonly characterized by lingual lesions 
Brown (1949) and others brought about the disappear- 
ance of lingual lesions in pernicious anaemia and 
steatorrhoea by the admmistration of calcium panto- 
thenate, inositol, nicotinic acid folic acid, riboflavin, 
and hver extracts Good therapeutic results were 
obtained in cases of glossitis in pernicious anaemia 
by treatment with pure vitamin B„ (Stone and Spies, 
1948 Schieve and Bundles, 1949) ' 

There is no explanation why so many cases of 
pernicious anaemia, well controlled with liver and 
vitamin B complex and showing an apparently normal 
tongue, still failed to exhibit fluorescence Perhaps the 
porphvrin-producing organism was not present in the 
bacterial flora Until this organism is^ identified the 
question cannot be properly answered 

Nothing defimte can be said at present about whether 
the fluorescence phenomenon is only a clinical curiosity 
or whether it has some value as a guide to the state of 
nutntion in the indiiidual Nor is anything known 


about the significance and ultimate fate of the por 
phyrin produced in the mouth It is reasonable to 
assume that at least some of it accompames the 
digested food to the lower part of the alimentary 
tract 

In addition, the role | of the normal bacterial flora in 
the mouth remains unexplained We know very little 
about the function of bacteria m the digestive tract of 
man and their influence on the nutritional state of the 
individual . Recent experimental work has opened a 
new chapter in the role of bacteria m nutrition 
(Elvehjem, 1948 , Johansson and Sarles, 1949) Lastly, 
an interesting hypothesis has been put forward bv 
Frazer (1949) on the part played by the bacterial flora 
in the sprue syndrome and in pernicious anaemia The 
importance of the intestinal bacterial flora in pernicious 
anaemia was stressed long ago by Davidson (1928) It 
IS also known that a number of vitamins are synthe 
sized in the intestinal tract, but, conversely, certain 
sulphonamides and antibiotics given orally may destroy 
the intestinal bacteria and change the microflora of the 
tract 

' « Summary and Conclusions 

The dorsum of the tongue often shows under Woods 
light an orange red fluorescence This is probably due trt 
synthesis of porphyrin by micro organisms 
The tongue has been examined in over 400 persons 
Fluorescence has been found in the majority 'of healthy 
individuals 

Absence of fluorescence becomes more frequent with 
increasing age it was found m only 11% of children but 
in 53% of people over 80 

In certain diseases — pernicious anaemia, hypochromic 
anaemia sprue syndrome and vitamin B deficienaes — there 
IS a higher incidence of absent fluorescence 

The vitamin B ^oup and iron have some influence in the 
restoration of fluorescence Antibiotics destroy fluorescence 
by their action on microflora 
The clinical significance of this phenomenon is not yet 
known Its possible connexion with nutritional factors has 
been discussed 

This work was earned out with the help of a Whaitt Kesearch 
Scholarship from Edinburgh University mainly m the wards of 
Professor D M Dunlop The antibiotic lozCnges were specially 
prepared by Messrs Duncan, Flockhart and Co , Edinburgh, to 
whom 1 wish to express my thanks 

1 ' 

References 

Bommer S (1927) Kim tVsehr 6 1142 

(1929) ,4c/o derm venereal Stockh 10 391 

British Medical Journal (1949) 1 672 

Brown A (1949) British Medical journal 1 1073 
Cami C (1934) Derm Z 70 189 , , 

Costello M J and Luttenberger, L V (1944) NY St J Med 
44 1778 

Davidson L S P (1928) J Path Bad 31 557 
Derrien E (1924) C R Soc Biol Pans 91, 634 
Elvehjem C A (1948) Fed Proa 7, 410 
Frazer A C (1949) British Medical Journal 2, 769 
Hagerman G and Hirschfeld R (1947) Acta derm venereal 
Stockh 27 369 

Hymans van den Bergh A A (1928a) Lancet 1 261 

(1928b) Dtsch med Wschr 54 1492 

Johansson tC R and Sarles W B (1949) Bact Rev 13 25 
Jones E O Figge F H J and Hundley J M (1944) Cancer 
Res 4 472 

Mackey D and Garrod A E (1925-6) Quart J Med 19 
. 357 

Mallinckrodt Haupt A S (1938) Z Vitamlnforsch 7 303 
Pappenheimer A M lun (1947) Fed Proc 6 479 
Poheard A (1924) C R Soc Biol Pans 91 1423 , , 

Schieve J F and Rundles R W (1949) J Lab dm Med 
34 439 

Stone R E and Spies T D (I94S1 Ibid 33 1019 
Thomas J and Bigwood E J (1935) C R Soc Biol Paris 
118 381 



Jav 20, 1951 HAEMANGIOMATOLiS NAEVI AND THORlU.Nt \ 


TREATMENT OT HAEMANGIOMATOUS 
NAEVI WITH THORIUM X 

ny 

R E. BOWERS, MD, BSc., MR.CP 

Assmant SHn Department St Thomases Hospital 

! insighlly nature of hacmangiomatous nacvi of the 
causes much distress anJ makes the patients or 
parents seek treatment in almost all cases The 
> t of this paper is to assess the results likely to 
r tamed ssith thorium X in the treatment of capillary 
and to make certain observations regarding the 
ation of this method 

Nalunl Hrstorv of Hacmangiomati 
ore considering how or whether these naevi 
nd to treatment it is necessary to take into account 
'ossibility of spontaneous resolution and for this 
isc It IS convenient to divide them into two common 
tics — the flat and the riiscd Histologically, the 
I I port Wine ) haemangiomata arc composed of 
id capillary like vessels while the raised (straw- 
ti ) lesions contain not only dilated capillaries but 
a' many large intercommunicating blood filled spaces 
wi h give them the name of cavernous naevi Many 
o( iicse raised lesions contain both superficial and sub 
Cl t meous elements or they miv be purely subcutaneous 
bill apart from their position in the skin, the two 
varieties of cavernous naevais appear and behave the 
sail c in every respect, 

Ihc so-called spider naevi arc really very small 
haemangiectases, sometimes of toxic origin as in liver 
disease They are not true naevi 

I xcept for the faint reticular lesions of the glabellar 
and nuchal regions, which often resolve spontancouslv 
(Ai cy 194-Ja), the flat capillary naevi arc ncarlv always 
persistent hence they arc often seen in adults 

By contrast, the raised (cavernous) naevi carry quite 
a different prognosis It was reahred for many vears 
(Stclwagon 1902 Jadassohn 1932a) that complete 
spontaneous resolution was a possibility later it was 
shown by Lister (193S) and confirmed by many other 
observers that the great majoritv resolve spontancouslv 
bv the ace of 5 or 6 — a happv outcome which differs 
from that of manv forms of treatment in that it is 
unaccompanied bv anvihine more than the faintest 
scarnng The ordinary caverno s lesions are never seen 
in adults It is not proposed to discuss their treatment 
here but the above remar) s do not mean that active 
thcrapv is never desirable 

Some haemanciomata remain fiat for a time but 
become raised by the third or fourth month of life 
these resolve spontancouslv m the same wav as the 
ordinarv cavernous naevi Thev provide however a 
possible source of error when one comes to assess the 
usefulness of a given Ireatm-nt for when the child is 
first seen the naevus mav be noted as " fiat o- 
"capillan Us sub'eqi cm disappearance is rcco'ded 
as the si,-cc"ful treatmeat of a capif’arv naevais 
whe eas it is ro hinc iro'c than the sp-satareous cu'c 
of a cavernous growth vvbich m ics ea best stages 
appealed fiat and who'e iricmaediate raised s-age was 
no. ebse-ved 

Vpat from cerfaia ram g*oa'‘-s ro' r''c"jo-'\3 be'e, 
them are two o„ sa-dre cxcep lo-s 'o the ge-rml ru’e 


that the raised haemanciomata disappear spontancouslv 
Both conditions arc uncommon, and both usually 
involve large areas of skin The first is the extensive 
slightly raised deep red stain on the side of the face 
which often covers an area roughly corresponding to 
one or more divisions of the trigeminal nerve it mav 
even bear pedunculated excrescences Tins tvpc is 
just as persistent as the ordinary port wine slam 
It IS sometimes part of the Sturge-Weber svndrome 
(naevus, buphtlialmos, pial angiomatosis and cerebral 
calcification on the same side, with contralateral hcmi 
picgia and often mental defect and epileptic fits) 

The second exception is the large spongy nised naevus 
which sometimes appears to be composed of varices 
and may bear areas of hyperkeratosis It is very 
unsighllv, IS cxlrcmclv difiicult to treat and may be 
accompanied by haemangiomata elsewhere than in the 
slin the underlying bones may he greatly rarefied 
In the ease reported by Silverman (1946) the patient had 
also a paraplegia due to an extradural haemangioma 
that author mentions several other eases in the literature 
J idassohn (1932b) and Ewing (1940) say that the expan 
Sion of such cutaneous naevi may do serious damage 
but this must be a very exceptional occurrence 

Treatment 

Treatment of ‘port wine stains has been and in 
many eases still is, very unsatisfactory, nearly all the 
common methods m use before the introduction of 
thorium X produced scarring or worse and thorium X 
was welcomed ns a practicable and apparently safe treat 
ment for these lesions Scholtz (1937) recommended it 
for this purpose Prosser Thomas (1 939) reported favour 
able resutts in an unanalyscd senes of 50 eases, and 
similar reports, but dealing only with one or two 
patients, came from Corsi (1943) and Feeney (1944) 

1 have been unable to trace my large series of cases 
treated in this way 

Tliorium \ is a radioactive substance whose prepara 
tion and properties were described by Lomholt (1923 
19j6) and more rcccnllv reviewed by Prosser Tliomas 
(1945) It IS sufiicicnl to say here that it has a half 
decay period of 3 64 davs emiltmg alpha particles o' 
such small penetrating power that when it is applied 
to the surface of the s) m m alcoholic solution its effect 
IS demonstrable histologically for a distance of only 
0 2 to O' mm beneath the surface Its effect is ven 
similar to that of a small dose of poorly p~netraling 
t rays short lived vascular dilatation progresses, after 
repeated doses to an obliterative endangiins the possi 
biiitv of senous skm damage is very small but is 
cons dered below 

Prevent Sludv 

l-ate in I9->7 1 began to review all available cases of 
hacmangiomatous naevus treated v ith thorium X at 
St Thom’S s Hospital The mveslieation was originally 
undertak'-n at the sucecstitn of Dr E W Pros’er 
Thomas n order to study the poss b'e octu'rerce of 
rad oJcTnatitis o- atrophy , but it «oon became e ideal 
as manv others have dsccvcrcd that the effects of 
iho'um \ oa these nae i are vanab'e in the extreme 
some pati'nls b-iag apparc-th cu'ed, vvhile oi'en 
receive little O' no brae't 

The r^t tncs and tb-ir -ccords wc*c ihercfo-e re- 
exaran-d la the hope of f-di-ag fo) the response to be 
cxpr» eJ from the .'ea.r-'"! of va- o s ’.pcs of aacais 



122 Jan 20, 1951 


HAEMANGIOMATOUS NAEVI AND THORIUM X 


Burma 

Medicai. Jouilkal 


and (6) the point at which treatment of unsatisfactory 
cases should be abandoned as unlikely to produce 
further improvement 

Mfftenal Available — The records of 48 patients with 
naevi treated with thorium X since 1939 were available 
^Four of these were not complete enough for analysis, 
nor could the patienjs be traced by letter , they 'were 
therefore omitted from the study The remammg 44 
were mostly seen by me personally 

Methods of Treatment — In most cases thorium X 
m alcohol, 1,500 ESU /ml, was applied by a slight 
modification of the technique recommended by Rox- 
burgh (1947) The erythema produced was allowed to 
subside and was followed about a week later by the 
next application, the interval between treatments being 
usually three to four weeks In some patients col- 
lodion was applied after painting, or the interval was 
reduced to two weeks or even one week when less 
mtensive ^treatment had failed , but, apart from an 
increased incidence and degree of erythematous 
reactions, the ultimate results seemed no different 

Radiodermatibs and Atrophy 

The possibility that these two ill effects might follow 
paintmg of the skin with thorium X has been suggested 
m the literature, but there is considerable uncertainty 
about their incidence, or even whether they occur at all 
in the dosage usually given (Airqy, 1944b , Feeney, 
1947 , Forman, 1948) 

Several authors state that they have seen a little thin- 
ning and atrophy of the skin as a result of treatment 
with thorium X, but these statements must be accepted 
with reserve, as this degree of skin change often follows 
the spontaneous disappearance of an untreated 
cavernous naevus 

In the present series no serious damage was seen 
which could be attributed to the thorium X The largest 
number of paintings recorded was 109 in about four 
years m this case one part of the treated area became 
pigmented One child, after 81 paintings spread over 
seven years, had questionable atrophy of the skin, with 
absent lanugo hairs on two small areas , one had a shiny 
and scaly appearance of the skin after about 63 paintings 
given over three and a half years but this child was 
a congerutal ichthyotic Two children had definite 
atrophy — one with pigmentation — after 16 and 24 paint- 
ings (Cases 3 and 17), but each of these hadliad carbon 
dioxide snow as well in view of the small amount of 
thonum X given, and the large amount used with 
impunity in other cases, it is probable that the carbon 
dioxide was responsible for some or all of this damage 
A boy (Case 30) developed stippled brown pigmentaUon 
after 54 treatments m two years 

It is not unusual to see a shiny appearance of the 
skin after repeated treatments Under the skin- 
microscope this appears to be due to hyperkeratosis 
m my experience it is reversible in its early stages, 
though no doubt it indicates the need for caution 

Results 

The results were grouped as follows (a) Good when 
the site of the naevus was invisible or needed at most 
a faint dusting with powder to make it so (b) Moderate, 
when there had been marked fading of only part of a 
naevus, or definite but incomplete fading of the whole 
naevus but only to such a degree that fairly heavy 


cosmetic applications were still needed (c) Bad, when 
there had been little or no change 
The differentiation of degrees (6)' and JjeJ was by no 
means^ easy parents are usually over-optiimstic, tending 
to see improvement where i none has occurred , this was 
confirmed in the few cases in which black and white ' 
or colour photographs taken at the begmmng of treat 
ment were available for comparison ' 

The clinical details of the cases are sutnmanzed in 
the Table Out of 44, the results were good, 20 , 
moderate, 12, and_bad, 12 
Good Results — Analysis of the good results discloses 
the very interesUng fact that 13 of the 20 cured had 
naevi which, though classed as ‘ capillary ” or ' pprt 
wine ’ when first seen, were raised at some stage of their 
evolution It is suggested that at least these 13 recovered 
spontaneously being in fact examples of small cavernous 
naevi , and that the thorium X was not an appreciable 
factor in their cure This hypothesis is supported by 
the following facts , (1) There was no raised naevus in the 
moderate or bad groups (2) Four of this group 
improved only a little during the treatment, but after 
wards disappeared completely (11, 11, 9, and 4 paint 
mgs) (3) Ten of this group at one time raised and 
subsequently cured had fewer than 25 paintings, and 
five of these had IS or less This contrasts sharply 
with the number of paintings given to the moderate and 
bad groups, in which few of the patients had under 30 
It would therefore seem that the degree of improvement 
was almost inversely proportional to the amount of treat 
ment, a fact showing ^sustained enthusiasm rather than 
therapeutic efficacy (4) The known tendency of 
cavernous naevi to spontaneous cure (see above) (5) All 
these cases were cured by the age of 4i years, by which 
time most cavernous naevi are known to resolve 
There remained seven patients m the cured group 
whose naevi were never noted as raised One of these 
was of the suboccipital type, with a known tendency 
to spontaneous cure The very httle treatment given 
to four others (2, 9, 13, 15 applications) makes it prob 
able that some of these, too, were cases of spontaneous 
resolution Of these seven all except one (aged 40) 
were cured by the age of 4 years 

Moderate Results — Of the 12 paUents noted as 
moderately improved all had flat naevi, the majority 
of which were small or faint at the start of treatment 
Their naevi have not regressed further since the discon 
tinuance of treatment, but in every case it was thought 
that treatment had been worth while 

Bad Results — ^The outstanding , feature here Ts the 
large number of applications which were given with 
no useful improvement 

Conclusions ^ 

It IS concluded from the above that, although many 
of the good results were unconnected with the use of 
thorium X, nevertheless the favourable results m the 
moderately improved group were due to that substance 
and It- IS thought that certain observations can be made 
which will help in the management of similar cases 
(1) Deep red capillary naevi are difficult to treat, whereas 
the faint ones are easier (2) A capillary naevus which 
is likely to undergo worth while improvement on 
thorium X shows definite signs of it not later than the 
twelfth painting a strong impression has been gained 
that even in these faiourable cases no useful improve 
ment is seen after a total of 30 to 35 appheaUons Case 5 



Jas 20, 1951 


HAEMANGIOMATOUS NAEVl AND THORIUM \ 


Ptrrm 

^fn^ c*.i Jo'tKit. 


121 


W'as the only exception to this rule — a woman of ••0 
who began to improve after 20 paintings and was \irtu 
alls cured after 64 in fise and a half jears (3) It is 
often stated that treatment with thorium X should be 
started as early in infancj as possible It is probable 
th I this idea has arisen because as m this senes a 
pr> portion of children seen in the youngest age group 
h t nacvi which arc going to heal spontaneously in 
the senes gisen here nre included patients of 44 40 
^ 13, and 10 who showed cure or improsemcnt while 

s'- \tren whose treatment was b'gun early are no more 
s I lent in the improved thin in the bad groups 

Ancillary Treatments 

VO patients who were considerably improved by 
" um X derived further benefit from pm point cautcr- 


ration of res dual teUngiectascs This can be done 
without anaesthesia in an intelligent adult it is not suit 
able for unanaesthetizcd children A loop-cautery must 
never be used instead of a pin point, as it leaves 
unsighllv pod lite scars 

Carbon dioxide snow is difhcult to control is 
unpleasant for the patient, and children treated by this 
method seldom return for a second application It may 
leave some atrophy and pigmentation if applied in ellcc 
tivc amounts but occasional good results may be seen 
in adults 

The use of hcavv cosmetic applications is of the 
greatest possible value when port wme stains persist 
into adult life Judiciously applied they can in most 
cases be relied on as an effective disguise and it is 
unfortunate that at present they arc so expensive 


Dctrits of Cotn 


<8 

Af St 

Stirt of 
Treatment 
Set 

Detcriiilon and Site 

No ■rf 
Faint 
Ingt 

Daratlon of 
Treatne'*! 

1 Time frem 

1 Lilt Treat 
i men! to Latt 

1 Etamlnation 

Rema ki 


7 mthi 

F 

S'ishlly riited »*nall fofe*icad 

Co^ 

40 

^ftu ft 

4 yn 

3 yn 

Some wtj VI "g a^J tr!i*'— <^aiU rrmiln ^ 

) 

iO*ki 


Itrg: left t 

i6 

S n£.S 

6 

S! c*f< atro'’\y S'tJ Np rca/r^-p 

A 

5 


Ratted Iffi ide o«xtput 

13 

14 

5 

Mad received fxir ap''!>cit m. o' CO* tno» 

Sh hi tc'a"'n*cta it and »nnkli-g remain 

5 

40 yn 

r 

Flat rore*ie3d and eyelid pmcnl at 

64 

yn 

6 nthi 

A few tclangt-^u ei retrain 

0 

? mth* 

r 

htrth 

S tfihtly raited tmall now 

It 

1 yr 

31 yr. 

Fad'd a»ajr after irea mert had been ittr'-wd 

12 

4 

r 

Flat forehead and note 

9 

7 tntht 

4 

No trace re'*atn» 

Sa.fut prewnt at end of trcatrvmt Pen fad d 

13 

8 a>Vs 


Slightly railed rt(ht teg 

4 

4 

31 

a»ay q iite q « Vly No trace now 

SI ght thtn in- of iVn and bafelx p-rce-llM# 
teUng ectatit f ad d after »to'’-l ftreatmenl 
SI ght sarieVlIng One of two telanr ctawt 

14 

9 mtht 


TeUnfiieetatlc naenii flat forehead 

2 

1 rnth 

4 

17 

l|)TI 

r 

Ratted note 

24 

2yn 

3 rnih. 

Thinrint oftkm and patch of aSient lanugo haJn 

3 

4 rotht 

Nt 

Rai ed eyelid 

ts 

7 rn hi 

1 yr 

MaJ rtoei ed 4 appl ^tioei of CO, mow 

No trace of ta ••■ui 

S 

3 « 

f 

Kawl fa-e 

21 

17 

i ypt 


/I 

3 .. 

r 

Slightly fa ted Iip 

28 

16 

8 niht 



5 

i 

SlightI) raiwvJ f>fehead 

te 

10 

*1 yn 

Faint Mje feck rtma nt 

31 

2\ >f» 

r 

I lit tmatl fa nt note 

25 

2>r« 

21 

Need a 1 itlr eo ering 

3. 

10 

y 

flatathmh later rated fa-^ 2letioni 

29 

H 

ll 

One If g-rt Oih r mo tH- slowly wIPo'Jl 

3S 

4 fpfhl 

r 

Flat n-vlffa ety faini rutcofneck 

6 

4 

6 n!‘'i 

f ftlser irtainvnt 

Fal da^ajlfh 

rv*gan tola rmly at end of trea m nt P n 

) 

9 

i 

I lat TO e 

15 

10 P" J»i 

4 

37 

2 nihi 

M 

Sligh ly raiwd face 

II 

10 

2 yn 

ii a— 5-1 ed in tho-Jt f re n mtht 

Fa d a«iT after a o-L-g ireatnent 

3^ 

<• « 

i 

IJat d*er red tmal front of neck 

13 

1 n 


IlotS c Vi— seired 

4’ 

lOvVi 

r 

a"d fa nt on glaSelU 

Rated n*ht Cheek 

9 

*nPi 

10 tr ’■1 

Fil d after tto~*5-girea •nent A few leorg ee 

6 

13 )n 

M 

X 

Flat faw< 

'xix - fir 
20 

Ij Tn 


law. re~i n 

Fo'ir ran later re'^-'t d by 1e ter I'-at I-ii*a 

f 

35 - 

r 

Pat fi'nj and rale*" ng*'t t.,w ceOk 

23 

21 

11 yn 

m** cnervnt tad n>t ma ained 

« 

44 

r 

and p — kr“t ttnee h rth 

Flat left » wen k a -xeAreJ o*’r jinoe 

*0 

1 yra^J 

Ffr r >ear» ti «t re’vrtcd lha tfra ■or-t 


i 

r 

aged 3t 

Pat p k left Sv^efa^ 

3 

4 nthi 

A-M-o 


1 c\ h-d aVjn bjt o^"^Ji d *wt> ■•'a vi itill 
r-ne-'l 

S-c md ciyinefin pa'J) J en at am hnn u 

IF 


F 

Ti 1 T* f- 

9 

34 

I*)44 

*i yn 

i 

J 

f *k. ' 

c aue wat i. icaa g- aa n. cn 

r rrJ 

Le ! r 1 F r’sr ha la r o ma'kf* a-f 

1<J 

24 - 


1 at fa e tna k d ic a -c«at'i » 

34 

*1 

7 r~ ^‘t 

C t ~a < y tcry g»3 ret- t a. rr tw cf p'- ::f 


i ^ 

r 

Flat fa-T Ixup — a 1 p 'k •'atcii 1 ' 

X7 

5| 

1 

3 j 

Ca— ef> 

XI 

4| 

r 

Flat fat e n e 

FI. fa^ pa w.*“ 

X 

M 

1 

* tstht 

p ^n of t ra ew a ea 

>3 

* »*kt 


. 1 

11 

“ r- 1 ) 

4 „ 

XT “J a » a f r*-t d n't 

4'> 

njn 

F 

r at Ti *1 r fa n It** ""h »*rTv^f a 

15 

J y. » 

6 ~ ) 

La e-a”*^! gi •*-. a rs-ott p-o* O cf’y 

4] 

4r* h» 

F ) 

and j" r - on to •n I \ “-.e : 

tfe < j 

Fla •'-a 3 i I . fa e and a-ck j 


! 

1 

1 

r“>-r*a 1 i- J - 

S ”lc--- f t ^ P-H "V * t I fa- t- Ifat 

1 

*7*7 

Tvl ^ 

• 

Pat. J r" faze c-ti ar- 

1 

1 

r-d / 

ft 

( 

1 

yn 

1 y- 

J — — : J" 

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124 Jan 20, 1951 


HAEMANGIOMATOUS NAEVI AND THORIUM X 


BlUTTSa 

Medical Journal 


Summary 

From the results of treating 44 haemangiomatous naevi 
with thorium X it is concluded that (1) Some patients 
denve useful benefit, but complete cure is not common 
(2) The complete and spontaneous resolution of slightly 
raised port wine ’ stains may erroneously be attributed 
to thorium X (3) Contrary to previous belief; the age at 
which treatment is begun does not affect the outcome 
(4) There is seldom any point in continuing treatment 
when improvement is not evident after 12 applications 
and it IS rarely necessary or desirable to use more^han 
30 applications in any one area (5) Atrophy or pigmenta- 
tion does not occur if moderate numbers of treatments are 
used 

My thanks are due to Dr G IB Dowling for help m the 
preparation of this paper and to Miss Pickering and the nursing 
staff at St Thomas s Hospital tor their assistance and con 
scienUous record keeping 

' References 

Airey F S (1944a) Proc R Soc Med 38 143 

(1944b) Ibid 38 142 

Corsi H (1943) Lancel 2 346 

Ewmg J (1940) Neoplastic Diseases, p 254 Saunders 
Philadelphia 

Feeney P J (1944) Proc R Soc Med 38 142 

(1947) Lancet 2 506 

Forman L (1948) Brit J Derm 60 219 
Jadassohn J (1932a) Handbuch der Haut und Geschlectskrank 
'heiten vol 12, part 2 p 405 Springer, Berlin 

(1932b) Ibid p 406 

Lister W A (1938) Lancet I 1429 
Lomholt S (1923) Acta radiol Slockh 2 437 

(1936) Brit J Derm 48 567 

Prosser Thomas E W (1939) St Thom Hosp Rep 4, 150 

(1945) Brit 3 phys Med 8 72 ■ 

Roxburgh A C (1947) Common Skin Diseases, 8th ed p 55 
Lewis London 

Scholia W (1937) Derm Wschr lOS 1242 
Silverman S (1946) Brit J Surg 33 307 
Stelwagon H w (1902) Diseases ol the Skin p 644 Saunders 
Philadelphia 


The December issue of (he Practitioner contains an 
mteresting expert article op the estimation of the prob 
able number of casualties in the event of atomic bomb 
explosion in Britain Flash burns should form only a small 
fraction of the total British casualties because the weather is 
seldom clear and the amount of haze will greatly cut down 
the danger area below the two and a half mile radius found 
in Japan, while high buildings and narrow streets will have 
a valuable shielding effect The fire risk is thought to be 
small apart from the danger of a fire storm like that 
which caused 40 000 casualties in a single raid on Ham 
burg The danger of exposure to gamma radiation is 
summarized in three tables which show the percentage 
mortalities at various doses as reported by the U S 
Atomic Energy Commission the shielding value of con- 
crete, and the probable casualties among a standard 
population (one person per 1 000 sq ft or 27 900 per 
sq mile) all in houses The first table ranges from 0% 
mortality for 100 r to 100% after 700 r with an LD50 
at 400 r At 2 000 ft over a mile from the explosion 
centre of a Nagasaki type of bomb a 30 in thickness of 
concrete will cut the radiation dose to 100 r and 32 in 
to 25 r while at twice this distance from the centre the 
required thicknesses are 16 and 21 in respectively Direct 
blast injury is of little importance because the blast pres 
sure necessary to produce serious injury is of the order of 
50-100 lb /sq in which is only reached directly under the 
bomb in an air burst at 2 000 ft The most important nsk 
of all IS from debris which is likely to kill over much of 
the area where gamma radiation is also lethal The final 
estimate of the authors is a total of 31 100 killed and 29 500 
mjured m a population of 43 per acre all inside houses 
or of 14,300 killed and 10 500 injured if everyone were m 
a reinforced bnck surface shelter 


Medical Memoranda 


Pemcilhn and Sulphamerazine in 
Treatment of Typhoid Garners 

Rumball and Moore (1949) cleared a chronic earner by 
use of a combination of penicillin and sulphamerazine 
They suggested that it was necessary to maintain the 
blood sulphonamide level at over 10 mg per 100 ml 
in order to obtain the full synergistic effect of penicillin 
Following this report, we treated three typhoid earners 
by this method 

V 

Case Reports ' 

Case I — A woman aged 63 had been in hospital 39 years 
She had had typhoid fever m March 1915 From that 
date until September, 1948, she had been kept on an enteric 
caution card, but was not recognized as a carrier Follow 
mg negative urine and stool exammations over a penod of 
three weeks and a negative Vi agglutination, she was taken 
off her enteric caution card Six months later on a rouUne 
check she was found to be excreting Salmonella lyphi 
(type F I) in both urine and faeces Penicillin 400000 
units every three hours was given (total 24 000 000 units) 
She also received sulphamerazine, 2 g eight hourly, to a 
total dose of 38 g Blood sulphonamide levels were esti 
mated on three occasions over the eight day treatment 
penod On the second day the level was 51 mg 

tree and 5 8 mg total' sulphonamide on the third day 

5 8 mg free and 5 9 mg total and on the eighth day, 

6 7 mg free and 7 mg total Penicillin estimations were 

not carried out During the last 10 month? repeated 
bacteriological examinations of both urine and faeces have 
failed to produce a culture of Salm typhi 

, Case 2 — A woman aged 64 Duration of present admis 
Sion 26 years Thire is no record of this patient ever 
having had typhoid fever, but she was exposed to an out 
break in 1915 when she had been a patient during an earlier 
admission There was also a further outbreak of typhoid 
fever in 1943 On repeated bacteriological examinations of 
excreta from all patients in the hospital one year previously 
she was discovered to be excreting Salm typhi (type E, 1) 
During the past 12 months she has been both a urinary and 
a faecal carrier She was given a combined course ol 
penicillin and sulphamerazine — 500 000 units of penicillin 
administered intramuscularly three hourly, to a total o 
30 000 000 units and at the same time 4 g of sulpha 
merazine in the first eight hours, then 1 g, eight hourly 
to a total of 25 g Eight days after the withdrawal of these 
drugs both her urine and her stools became positive to 
Sa/m typhi ' 

Case 3 — A woman aged 67 had been in this hospital 19 
years Again there is no history of typhoid fever She was 
however in the hospital during the minor epidemic of 1943 
She has been excreting Salm typhi (type F D m both unne 
and faeces over the past 10 months This patient wa 
treated similarly as Case 2 with equally disappointing resu s 

Comment 

In Cases 2 and 3, which failed to respond to treat 
ment, the blood sulphonamide level was maintaine 
above 10 mg per 100 ml 

The problem of a typhoid carrier in a mental hospital 
IS one that must continually subject the authorities to a 
certain amount of anxiety, and particularly that of the 
carrier from the ambulatory or undetected chnical case 
Ilf all cases of pyrexia of unknown origin occurring tor 
three days or longer typhoid fever should be excluded 
The history of these three patients shows that only one 
had had a definite record of typhoid ^fever , the other 




J^s 20 1951 MEDICAL MEMORANDA i;^ 

l 

(WO were apparenllj undetected ambuhtorj ca>;cs md When ibe p'r c'e< d i'-- NSn e-w cnDii'r 


were able to develop a chronic carrier state Despite 
the variety of medical and surgical procedures that have 
been advocated to rid the individual of his carrier con 
ditin and despite the introduction of chloramphenicol 
It V old appear that the treatment of the earner state 
in tv hold fever still has to be solved 

'' ' avc to IhanV: Dr J S McG epor the n dical sursmlcn 

d or perir vv.on to publish this paper Wc ssould at o tike 
to f CSV our thanks to the nursnp s aft conccrticd 

ADM Douglas MB, D P H , D P M 
Senior Prpslrar 
D C Hunnsno AIMLT 
Senior Labora orv Technaan 
S ate Hospi al 

IifTc-on Trent Notts 

IlrtTpr T 

I tl C A and Moore L G (19 9) dr/ilih ffejieel 
iirrat 1 615 


\ Case of Pethidine Sensitivity 

I ollovving CISC IS of interest in \icv. of the intro 
dL of mtra\cnous pethidine as an anacsthciic agent 
to tjppicmcnl nitrous oxide Tnd ox>fcn (Mushin and 
Rc -'ll BaVer, 1949) 

Cast RrroPT 

Tb patient a uoman aped 26 v\ciphed 7 st 6 lb 
(47'' kp) and her pre*cpcnlivc blood pre^^surc was PO/ 
86 n Up Apart fron a historv and findings indicating 
a pt nc ulcer for which aapoicm) was to be performed 
she as in pood heslth There was no histoo <'f prcMous 
illness 

Prcmedication with morphine 1/6 pr (11 mp) and atro 
pine I/ICKI pr (0 6^ mg) was piscn subcutancousl) and 
one hour later a tc<l do<c of pallammc tncthiodid'‘ 
( fiaacdil ) 20 mg was pisen ntraNcncuslj into the left 
arm after three minutes «hc complained of tiredness and 
dip’opia As rcspintora difficultv did not occur a funber 
60 mg was piscn followed immediatcl) h> 05 p of ihio 
pemone The lungs were inflated cvcral (ernes wuh exsgen 
and a «i7c 9 cuficd endolracbcal tube lubricated with 
nup-rcatml** was pa«^ed b) direct lar>ngoscop> sm hoot 
an\ di^’inilts Tlic tube was cnnncLted to a Waters 
a«' nM> the cuf^ w-as infaled ard a mixtv rc of 1 litre 
of exspen wjih 2 1 tres nitrous oxide was piscn m a 
few cconJs ih* patient took a b e~th ard soon beg-n to 
b calf c rcgularb 

Jl^t be'o c tbc ppe^tion f arted 2' nc cf pethidine was 
poen i'*trase'‘ousU jnlo tbc ngbt arm and the ssnrrc 
strapped on The patient b'^came ap^o-ic ssubin sc^o^ds 
and wns irfa -d rhs’Jn call) wi h a nitrous ox de-<jxsg-n 
nix ire the bap bci-g enp icd (■» the air and refilled wnh 
fresh g 2 *'*s esm n -u c o «o W'b'*n l^e a^do'rnal j-t 
s i.-'n was nade it was no ic^d that tb-'c was sen li il- 
bV*di''p a’-J t''e temp'^ral pu’s** ss^'ich was 1-0 a r-n*, 
w^i c' P'S - so^u'^^ and fc'"*n cov’d no be fe’t at all No 
b on 5 pTs' read "p co ’d b- e h* bv p-lpa 

c b\ ax*s-L’ - n" «a b** pa •"! w^s p,t :n a ‘‘c^d 
d t-n tvIl I was rc-«u'— 'g tb s' - Ve~ a gN^d col'' 
a-d as capi '*r\ rc^d i*"- v s o“ls sc-n I> re anf-d 
-o r n--s^ rs s-c'e taken 
Tb- op^*a’:on was c - s ^a i- p*'- I •* 

d*^i*>-d as p^r^t -g C"-.. a-d a c'* c 

9ti\c a-d pr-^s \ tca^T-d t c— was f-'^-d n fn p 
jv. A ps’'‘apa s -d a**d 

os>a d« r-d t ' 1 '' s s p- r-vtra ''•* 2^ 

r~ cs a' t''- p' d - Ivd p S'— a ssa ^ *• p-^s 
o' *0 n— Hr wsy j — d-i -“d s^pjs 

id— ** d a-d d ' d-^d M ■* r p •“» 

; en — L .-d t' r - - r — 

r-.dy a 12.’' a “w - lb » — 


renosed and il - Lnps nfa’cd fisc or six tin-s s'l h pt rc 
ox>gcn to de c rnne ih- d - h o' i’'acs’^'‘sn ssi ' in a few 
-cenjs the pslicnl f'ok a deep b cath rnoscti 1 -r am* 
and s Tinkled b-r fore’ -xd so the Tow o' mtrt s oxid- 
w % resumed aril t''e sods Im- -ep’aeed b'*- continued to 
brcxlh- artd <el Jed down in n few (1- <km i-a 

sicn which h d b -n dr> b-gm to b’-ed bnsk!) the s>sto!ic 
pressure hnsing ns^n to !0^ r^n Hg When tbc pc hidin- 
sjnnge was rerrosed from the arm a skin sscal s%ns fund 
running proximalls for nb''ul 4 in (10 cn ) it was cxnctU 
supcrfi nl to d - course of the scin nnd rernned for a 
funher two hours 1 --'nrc pndmlls d sippcnnng 
At the end of the ope ation irachco bronchnl toilet wis 
perfom-d and the endo ra-hcnl tulc rerrosed after b cath 
ing pure oxsgen for !c»s than tsso mini cs the pxiicnt 
regained full cons loiisncss anss ’•-ed q\ c' tons irtcllipcntlv 
and corrphincd of h-adicbe She was returned to l^'d and 
kept Imd down for six hours but ro furtber ill c'Tcc s sserc 
seen The duration of ries besn w is on- and n half bourn 
Apart fron slight nl domiml discomfort on the fi Ilownng 
da> reco\cr> wns lincse-tful the patient ssas up cn the 
third das and went hone 12 dnss after op-ration 
As no account of n similar occurrcrcc could I c found In 
the iPcraturc an attempt was made to investigate it ard 
to d-sensiti/c the patient An infnd rmil injection of 
0 I ml of p thidirc solution (1(V> mr in 2 ml ) produced 
in the patient a skin weal 2 cm ir diam-tcr there being 
no respons- to a control o' normal salin- Controls in 
normal solunicers shossed that p-lhidinc in M^clf prodi ccs 
a weal in all cases thouch it has been stated thit p-thi 
dine artagonires histamnc (Gnib-r rt rl 1941) It has 
also been learned that a sul cutaneous weal running along 
the vein is not an bnusuat finding though not proioi s1> 
d-scribed when rep-ated doses o' p'^thidine are given 
throuch an ind selling intravenous n— die In ore con 

sidcrablc series o' ca es it s as present quite often and In 
Itself IS ..pparenti) of no sirnifi-ancc fU J Wo’fson— 
pcrxo''a! communication) 

Further inj ciions of 02 0’ ar'd 0 5 ml o' p- hidmc 
solution copiaining 10 15 and 25 mp o' p-ihidin- rc pec 
tisciv were given subaitancou'l) at hourlv intervals with 
(he hop- of d-sTsiiirirg tie pa’i-nt One week Later a 
sloss intravcpous inj-c inn of '0 mg of p-iludmc w is given 
ard blood pressure readings sserc (a)cn apart fro-n slight 
dros-sjpcss whi h p-rsis ed for an hour or two ro c"cct.s 
were nppare-I 

Although hvpotension rcspirato-x depre sion ^nd 
bradvpnoca have b-en noted with larger dns« of 
p-thidinc both in animals (Griibe- r/ cl 19-«1) and in 
nv osn clinical exp— 'ir'-c no c e of t^is s-verit> has 
xcl been repa ted in which the blood p cssu-c wa' 
unrccc^dab'c fo- 20 minutes and in wb -h apno-a— 
p-obabH p o’onged b\ ’’capno'^a m the late- < ages— 
a*'d p-rfee* anaestbex a lasted fc one and a hv.lf hours 
aftc- tnc rchtivelv small do - of 25 rr-* h '—ms ad as 
al'e to give a p test do e of 10 rr- of p^h dm- 

int-'vcnoLsh wlen s rr-l’'od of '•n-c- ^csia is lo be 
LS-d 

I .m t- * ** d to HD' rre Je'-'c-n f- pr— n.i -rs to 
rr'> *1 1 : ce • f'T D II X\o i D x n «'d D- J A S— 
c' t'- To -"d- - *t-d ^ Lr-J— '''f r 

C'd tdx a"* o D L. J %Vr tt— ^ ctr"- i- a-jt't 

V. fi ^ J mtt-'g ara 

\ c - eal tod^rgx 

D /ter ''B_ OB DA 

i-i r P— j~* t- t''-* TV— A' — 

Ic- -- i_-3 , ra»S c'lr- - 

Prrne ee 

Hr- r P^a'iC-vV* C ?',p- J 

A. t-d P— vd' ” tr- L. /i T' ~ 

2 ^72 



126 Jan 20, 1951 


REVIEWS' 


3unxR 

Midical Jouuol 


Reviews 

t 


HAY FEVER 

Hay fever A Key to the Allergic Disorders By John 
Freeman D M (Oxon) (Pp 321 71 figures £2 2s) 

London William Heinemann Medical Books 1950 

It IS a pleasure to review this book, for it is not only 
full of first hand information but is in its way a work 
of art^ It IS so clearly written that it can be easily 
understood by any interested layman , moreover, it is 
beautifully produced As the author states in the fore- 
word, it IS an account of his stewardship to Leonard 
Noon, his former colleague, and by implication to 
Almroth Wright, his mentor ' 

This IS not a textbook but a record of Dr Freeman s 
life s work and experience, which he recounts in a con- 
versational style illuminated by a lively sense of humour 
His chief concern is with hay fever, but he discusses 
asthma almost equally fully Throughout the book there 
IS a wealth of small clinical observations which add 
greatly to its interest where else, for example, is noted 
the frequency with which pdllen settles in the external ' 
auditory meatus, there to set up its intolerable itching 
m sensitive patients 7 Case histones are abundantly 
used , they are often amusing and always concise, so 
that the appropriate point is made without the distrac- 
tion of unnecessary information The humorous cap- 
tions to the anecdotes enable them to be indexed m a 
simple and effective way 

Although Dr Freeman ts chiefly concerned with the 
problem of sensitization as the basic cause of what he 
prefers to call ‘ toxic idiopathies, he is no bigot He 
takes care to point out that no single cause can entirely 
account even for hay fever, which is generally regarded 
as the most definite example of allergic pathology, and 
that no one method of treatment is effective in every 
case 

The chapters on the effect of the emotions are par 
ticularly clearly written and reveal great insight into 
character and specially sympathetic understanding of 
the feelings of children Although the author sometimes 
tilts at psychiatrists it is evident that he attaches con 
siderable importance to the mental state of the patient 
The problem of infection is fully discussed, and his views 
on how bacteria produce their effect in allergic dis- 
orders are interesting and original Whether specific 
sensitization to bacteria does in fact cause asthma is a 
question he wisely leaves undecided but he gives sound 
reasons for believing that bacterial toxins will enhance 
the action of pollen and other sensitizing agents 
In the chapter entitled Serous Leak ” he suggests 
that acid fruits cause urticaria and other allergic symp- 
toms by altering the concentration of lonizable calcium, 
so that blood is made less viscous and serum leaks more 
readily through the capillary walls There is little evi 
dence to support this view 
The author gnes full details of his methods of pre- 
/panng extracts the technique of diagnostic skin reactions, 
and desensitization One cannot help admiring the cour- 
age of a doctor who teaches the patient to give him 
self 54 mjections and like it but insists that no attempt 
IS made to sterilize the skin beforehand It is reassuring 
to know that no case of local or general sepsis has been 
recorded from among more than a million injections 
gi\en m this way The use of \accmes is also discussed 


Dr Freeman dislikes medical jargon and is “ allergic ' 
m the sense of his third definition of this word to many 
terms in common use, including “ allergy,’ atopy,’ and 
immunity’ While admitting that these and similar 
words are often used inaccurately or in different senses, 
so jthat It IS imperative for an author to make clear just 
what he means when he uses them, the reviewer is doubt 
ful whether the invention of an entirely new set of terms 
(toxic idiopathy, idiotoxin, phylactology, pathbphane) is 
a satisfactory alternative 

While, unable to agree with everything Dr Freeman 
says, one is never in doubt 'about what he thinks or 
about his reasons for thinking as he does What he says 
IS the result of his experience, and he stmuilates the 
reader This is a book that -any doctor will read with 
pleasure and benefit, but it must be read by all who arc 
interested in the study of allergy ~ , 

R S Bruce Pearson 


SALTY WISDOM 

The Four Pillars of Wisdom A Rational Approach to 

a Healthy Education By Surgeon Vice Admiral Sir 

Sheldon F Dudley KCB FRS (Pp 246 gs 6d) 

London Walts and Co 1950 

Looking at the short title on the dust-cover, one 
wonders what may be the nature and the contents of 
this book, a product obviously of relative leisure which 
the distinguished! author has enjoyed after his retirement 
from a turn of duties as strenuous, and as'heavy with a 
tremendous responsibility to the nation and to the 
worlds future, as the Royal Navy can ever have 
laid upon any of its medical officers, for he was 
Medical Director-General of the Royal Navy from 1941 
to 1946 Is It a record, one wonders, of experience accu 
mulated durmg earlier and, perhaps, more vanously 
adventurous years in that great Service 7 The title page 
adds the explanation , Admiral Dudley ^has been lookmg 
back over a career which has, indeed, been unusually 
varied in achievement and distinction — not many serving 
naval surgeons have become Fellows of the Royal 
Society by right of their own researches — and he has 
been wondering whether the kind of formal education 
which he received helped or hindered him in the things 
that matter And in this discursive, uninhibited, anec 
dotal, often amus|ng, and always interesting and stimu 
lating book he records for us his own conclusions and 
shows us how he has reached them ' It requires,” he 
writes, “ a slightly more than average mtelhgence and 
self discipline to accumulate medals and a post titular 
alphabet — but no wisdom 1 So far as he has attained 
the wisdom which it should be the first aim of education 
to produce, he has had to do it by the hard way of 
"largely unguided experience , and now he has found time 
to give us his conclusions on what education should he 
and might be 

The ‘ Four Pillars of the title, the main components 
of the structure of a true education should, he con 
eludes be semantics (he was first impressed with the 
importance of this by reading Ogden and Richards on 
The Meaning of Meaning), psychology, statistics, and 
logic These, he urges have a fundamental significance, 
a prime necessity for a scientific education as distinct 
from an education in science But Admiral Dudley is 
not concerned with the detailed method of introducing 
them into an educational syllabus) it is not his aim to 
write a textbook of education The four pillars serve 
him in the book as supports or pegs for a structure 




Jan 20 1951 


REVIEWS 


BRiTtxa 

Medical Jouwul 


127 


of personal musings, arguments '■and reminiscences m 
which the ordinary reader, and the med'cal reader more 
particularly, will find matter much more attractive for 
the occupation of his hardly won leisure than any more 
formal treatise would be likely to offer There is a 
breezy freshness about the book which carries the reader 
easily along and the chapter headings in spite of their 
suggestion of an intellectual severity do not hinder the 
author from any kind of digression which the natural 
vagaries of his interest may start Under Psychology 
there is a subsection on religion and we have Admiral 
Dudley s views on this, as on all subjects, with a down 
nght directness We gather that he is not in favour of 
It in any orthodox form as a self confessed pre 
judiced medical man wth a personal grudge against the 
priesthood as a profession ’ 

Emphatically a book to be read and enjoyed, packed 
full with the fruits of a salty wisdom 

Henry Dale. 

nANATOMY of the healtti service 

The National Health Service By Roger Ormrod M A 
B M B Ch (Oxon 1 and Hams Walker Annotations 
to the National Health Service Acts 1946 and 1949 
by John H Ellison M A (Cantab ) Reprinted from 
Buttcrworths Annotated Legislation Service (Pp 241 
£1 7s 6d plus Is Id postage I London Butlerworth 
and Co (Publishers) Ltd 1950 

The preface to this book states (hat it is designed to 
provide a detailed account of the National Health 
Service Acts of 1946 and 1949 and the principal statutory 
mstruments which give effect to the Acts The authors 
give a detailed^exposition of the Health Service, with the 
texts of the Acts and of the principal statutory instru- 
ments (up to June, 1930) They are both barristers, and 
though one of them has also a medical qualification the 
book IS written entirely from the legal point of Mew 
They display the dry bones of the Service accurately on 
the whole but without the flesh and blood with which 
those who have to work the Serrice have clothed them 
and without which it could not function Curiously 
enough the only major blunder discovered is the defini 
tion of a hospital (p 6 last two lines) where by careless 
condensation of the words of the Act hospitals are made 
to be convalescent homes instead of including them 
It will be convenient no doubt for many people (but 
chiefly for lawyers and administrators) to have the text 
of the Acts and the principal statutory instruments in 
one volume , but the flow of amending regulations and 
rules necessitated by the growth of a large service will 
make very frequent supp'ements or new editions neces 
sary if the book is to retain its value as a work of 
reference 

F Gray 

GYNAECOLOGY IN PRACTICE 

Medical Gynecology "By Professor James C Janney 
M D FACS Second edition (Pp 454 illustrated 
£1 12s 6d) Philadelphia and London W B Saunders 
Company 1950 

This IS a happily arranged httle book designed for 
general practitioners and m"dical students It presents 
the practical and clinical approach to the subject Each 
chapter is on a symptom^rather than a disease the sig 
nificance of physical signs rather than pathology , medi 
cal and physical methods of treatment rather than the 
minutiae of surgical operations In one section the 
author considers the principles and applications ^of 


special tests and in another discusses at length the impor- 
tant sociological problems associated with gynaecology 
There are few textbooks which devote so much space 
usefully to consideration of marital maladjustment and 
Its prevention and treatment 
Ideas of what a candidate should know of gynaeco 
logy at the tune of final exammation, have changed 
considerably in recent years and teaching is being 
modified accordingly This book is a serious and satis 
fying attempt to present the new outlook avoiding so 
far as possible all that comes within the province of 
the specialist It concentrates on the problems as they 
present to the general practitioner and on the forms of - 
treatment which fall wifhin his sphere / 

T N A Jeffcoate. 


BOOKS RECEIVED 

Reideie is not precluded by notice here of books recently received 

A Synopsis of Fevers and their Treatment Issued by 
Virol Limned 9ih -cd (Pp 192 2s 6d ) London Virol 
Limited 1950 

Industrial and Safety Problems of Nuclear Technology Edited 
by Professor M H Shsmos and Professor S G Roth (Pp 368 
28s ) London Hamish Hanulion 1950 

The Cerebral Cortex of Man By XV Penfield C M G M D 
B Sc D Sc F R F R S and T Rasmussen M D (Pp 248 
48s 6d ) London Macmillan 1950 

Cell Growth and Cell Function By T O Caspersson M D 
(Pp 185 28s ) London Chapman and Hall 1950 

The National Health Service ^ Act sp^S Annotated 
Supplement to sppS Edition By S R Speller LL B (Pp 285 
27$ 6d) London H K Uwis 1951 

A Textbook of Histology By Professor E ^V Cowdry 4lh 
revised ed (Pp 640 60$ ) London Henry kimpton 1950 

Whitaker s Almanack ipyt By J Whitaker F SA 
(Pp 1 156 Complete ed 12s 6d shorter ed 7s 6d ) London 
J Wbilaker 1950 

An Addendum to King's and Some King s Men By H 
Willoughby Lyle MD FRCS (Pp21I 30s) London 
Geoffrey Cumberlege 1950 

Atoms and Atomic Energy By R W Hallows TD MA 
M I E E (Pp 196 10s M London Chapman and Hall 

1950 

Handbook of Diagnosis and Treatment of Venereal Diseases 
By A E W McLachlan MB Ch B DPH FRSEd 4th ed 
(Pp 368 17s 6d) Edinburgh E and S Livingstone 1951 

Introduction to Diophthalniology By N A Slutterheim 
M D (Pp 43 7s 6d ) London H K Lewis 1950 

Principles of Internal Medicine Edited by T R Hamson 
BA M D (Pp 1 590 90s ) London H h. Lewis 1950 

Thomas fV Salmon Psychiatrist By E D Bond M D 
(Pp 237 15s ) London Chapman and Hall 1950 

Genetic Neurology Edited by P Weiss (Pp 239 $5 ) 

Chieago Universiiy of Chicago Press 1950 

L ipilepsie Expenmentale By Professor G Morum 
(Pp 139 No price) Pans Hermann 1950 

La Stdnlite Uiialontaire By R Palmer '(Pp 493 1600 

francs ) Pans Masson 1950 

Hiriidurchblutiingsstorungen By Dr A Brobeil (Pp 264 
M 45 ) Stuttgart Georg Thieme 1950 > 

Allgeiiietne Pathologic By Professor F Buchner (Pn 528 
M 32 80) Berhn Urban and Schwarzenberg 1950 



128 Jan 20, 1951 


THE SYMPATHETIC TRANSMITTER 


BumsH 

MnsiCAL JOUMOL 


BRITISH MEDICAL lOURNAL 

LONDON 

SATURDAY JANUARY 20 1951 


THE SYMPATHETIC TRANSRHITER^ 

The account of the hormones of the sympathetic ner- 
vous system and the adrenal medulla in the opening 
pages of this week’s Journal is of particular interest, 
because it is written by Professor U S von Euler, 
whose work m the penod 1944-6 did much to focus 
attention on the substance noradrenaline In struc- 
ture noradrenaline is similar to adrenaline except that 
the mtrogen of the amine group which terminates the 
side cham is not methylated, and in German it is 
“N ohne radikal” Professor von Euler demon- 
strated the presence and estimated the amount of 
an adrenalme-like substance m many organs and 
nervous tissues and showed that the compound had 
the properties of noradrenahne The amounts were 
greatest in sympathetic nerves thus the thoracic and 
lumbar sympathetic chain and the splenic penartenal 
nerves contamed as much as 30-100 ng per g He 
inferred that noradrenaline iS the physiological trans- 
mitter of adrenergic nerve action and supported this 
inference by the observabon that after the nerves have 
been cut and have degenerated noradrenahne almost 
entirely disappeared from the organs supplied 

The spleen has been found to contain, per gramme 
of bssue about 25% of the amount of noradrenahne 
m splemc nerves But the nerves withm the spleen 
do not consbtute a quarter of the spleen bssue hence 
It seems as if there must normally be a bansport of 
noradrenahne down the nerves mto the spleen m 
which It presumably exerts some funcbon hitherto un 
descnbed The sympathebc bansmitter is not enbrely 
noradrenahne but appears to be a mixture of nor- 
adrenalme with a small amount (perhaps 5%) of 
adrenaline There is considerable diEBculty in esbma- 
bng mixtures of this kmd when the amounts avail- 
able are small and it is nght to pay tnbute to the 
pamstakmg work which has been done on this sub- 
ject m the pharmacological department m Edmburgh 
So far as is known at present there is little evidence 
of excess of noradrenahne m the blood m clinical 
conditions except when there is a tumour of the 
adrenal medulla These tumours contam mainly and 
sometimes almost enbrely noradrenalme and they 
give nse to a large excrebon of this substance m the 


urme — so much that the unne causes a nse of blood 
pressure when it is injected without treatment into 
an anaesthetized cat Therefore to diagnose an 
adrenal medullary tumour it is better -to examme 
the urme rather than the blood Von Euler and 
Engel have shown that when a tumour is present the 
normal excretion of 30 ^tg of L-«oradrenahne and of 
10 jtg L adrenalme per day nses to more than 1 mg 
Professor von Euler discusses many of the mterest 
mg differences m the physiological properties of nor 
adrenalme and adrenaline When given to man m 
amount which causes a large nse of blood pressure i 
noradrenalme does not cause the anxiety, discomfort, 
and irritation which are caused by adrenalme More 
over, Goldenberg and his colleagues have found that 
there is an important difference m the effect of the 
two substances on oxygen consumpbon in man 
When infused mtravenously at the rate of 0 15 (ig 
per kg of body weight per mmute, noradrenahne did 
not affect oxygen consumpbon, whereas when adrena 
Ime was infused m the same amount the oxygen con 
sumpbon was mcreased by 25 % It is clear that there 
are sbll important gaps to be filled m our knowledge , 
before a correct estimate can be formed of the physio 
logical roles of the two substances When the physio 
logy is clearer the part they play m pathological 
condibons wiU also be more evident 


TfflACETAZONE 

The last five years have seen the mtensive study of 
five chemotherapeubc remedies for the treatment of 
tuberculous mfecbons Calciferol (vitamm Da) has 
a curabve acbon only m tuberculous lesions of the 
skin and its use m pulmonary tuberculosis seems 
to be definitely contramdicated The sulphones have 
proved disappomtmg m tuberculosis but^m the other 
great infection caused by an acid-fast bacillus, leprosy 
they are undoubtedly of very great value, especially 
the parent substance 4 4 '-diammodiphenylsulphone 
Sbeptomycm has been studied more mtensively than 
any of the other drugs Its acbon, although most 
remarkable m miliary and menmgibc infections, is 
now known to be bactenostabc rather than bac 
tencidal and some well-known disadvantages un 
doubtedly attend its use Tubercle bacilli resistant to 
sbeptomycm have been recovered m the USA m 
France and m Great Bntam from patients who have 
never themselves received the drug P A S (p ammo 
salicylic acid) though less acbve than sbeptomycm 
IS also less toxic and there is now growing evidence 
to show that treatment with sbeptomycm and PAS 
m combmabon retards the appearance of sbams resis 
tant to sbeptomycm ^ Of the fifth anbtuberculous 



Jan 20 1951 


THIACETAZONE 


Bwma 

Moicax, JoinuuL 


129 


drug, thiacetazone much less is known, at any rate m 
English speaking countnes 

In 1946 Domagk and his colleagues- m Germany 
reported that, among a number of thiosemicarba 
zones p acetylammobenzaldehyde thiosemicarbazone 
was the most active agamst tubercle bacdh in vitro 
and also in experimental animals ’ Thiacetazone as 
It IS now officially called has m the past suffered from 
a surfeit of names In Germany it began as “ conte 
ben ” or TBI-698 other proprietary names are “ ber 
culon A ” “ seroden ” “ thioparamizone ” “ tebasid ” 
and “ thiotebesme ” The action of thiacetazone on 
tuberculous infection m mice was confirmed by 
LevadiU,* who found it mfenor to streptomycm but 
comparable m effect to PAS Experiments by 
Behmsch and his colleagues® ' suggest that the sul 
phur atom is essential for antituberculous activity 
that compounds derived from aldehydes are more 
effective than those obtamed from ketones and that 
the aromatic aldehydes yield more potent compounds 
than the aliphatic aldehydes ^The mtroduction of 
substituents mto the aromatic rmg is also said to 
increase activity Hoggarth and his colleagues’ 
examined a number of thiosemicarbazones and found 
that though thiacetazone was effective m mouse m- 
fections, yet p ethylsulphonylbenzaldehyde thiosemi 
carbazone (termed by the Germans Tb III Be 1374 
and m this country “berculon B”) was even more 
effective and certainly surpassed PAS though not 
streptomycm The relationship between the two sub 
stances can be seen from the structural formulae 

OI.CO NH CH =N NH CS NH, 

Thiacetazone 

QHsSO, C3I=NNHCSNHj 

p-Ethylsulphonylbenzaldehyde thiosemicarbazone 

Hamre and his co workers* examined nearly 100 thio- 
semicarbazones and related compounds and found 
that only eight were active agamst tuberculous infec- 
tions m mice In order of potency the substituents of 
3 thiosemicarbazone are ethylsulphonyl iso propyl 
anuno ^acetamido dimethylammo, mtro, sulphamyl, 
methoxybenzaldehyde Although only compounds 

^ Medtcal Research Council investigation reported m the Bn(ish Mfdical 
Journal J950 2 1073 

* ^ It 3is 

>48 39 1322 

UfM. JJ 

® Amer Rev Tubere 1950 6t I 

1 ry r> — » o o > -Id® 


Arch Otoi A r iy**v W 
Proc MoyoClm 1950 25 160 
‘oSchHtC, mfd Wrehr 19SQ 80 373 
*1 Lanctt 1950 2, 286 


active in vitro have an effect m the mouse there is no 
correlation between the inhibitory activities m vivo 
and in vitro ’ 

Thiacetazone can be given either by mouth or 
parenterally It is not very soluble m water, but solu 
tions can be made up m propylene glycol and some 
acid amides A method of estimatmg the amount of 
thiosemicarbazone m body fluids has been worked out 
by Spinks ” The agreement between the amount 
m the blood and the therapeutic effect suggests that 
the thiosemicarbazones act directly rather than after 
conversion m the body This is borne out by the fact 
that thiacetazone, in addition to inhibiting the growth 
of tubercle bacilh in vitro causes morphological 
changes such as abnormal size granular dismtegra 
tion and the appearance of delicate threads Bacilh 
first of aU lose then capacity to take the Ziehl-Neelsen ' 
stain and finally the Gram stain It seems probable 
that thiacetazone combmes with one of the blood pro 
terns One way m which it is supenor to P A S is 
that It IS not inactivated by p aminobenzoic acid 

From 1947 onwards a very large number of cases of 
^11 forms of tuberculosis have been treated m Ger 
many “ ” Many of the treated cases, however, pro 
vide httle or no real evidence of cure, smee there were 
no controls and the period of observation was short. 
In Germany the assessment of the value of a new drug 
has been specially difficult because of widespread 
malnutrition and a shortage of x ray films Hinshaw 
and McDermott’* reported their observations after 
visiting 10 of the larger German centres where the 
drug has now been m use for four years The best 
results have been seen m “ fresh exudate ” types of 
pulmonary infection and m laryngeal and mtestmal 
tuberculosis In some cases of tuberculous eye infec 
Uon cures have been claimed “ In imhary infections 
and in tuberculous menmgiUs results are far mfenor 
to those obtained with streptomycm The dosage 
used has been low— 25-50 mg daily for the first 
week or two, with a gradual mcrease to 200-300 mg 
daily if the patient can tolerate it Some workers pre 
fer a maximum of 150 mg daily Treatment must 
be continued for 6 to 12 months 

While the therapeutic activity of thiacetazone still 
awaits critical appraisal there is evidence to show that 
It IS by no means non toxic Anorexia constipation 
malaise dyspepsia palpitation, dizziness, pain in the 
eyes, photophobia blurred vision and headache 
often occur but vomiting is less common The 
more severe reactions, occumng it is said m about 
0 4% of cases, consist of toxic erythemata conjunct! 
vitis, cerebral oedema, anaemia, and granulocyto 
penia Fatal jaundice of hepatotoxic ongm has been 
reported Oedema of the bram with severe fatty 
degenerauon of the hver parenchyma was seen by 



130 Jan 20, 1951 ' 


thiacetazone 


Medical Jouexal 


Heepe“ m three children who died after treatment 
with thiacetazone A tendency to haemorrhage or 
purpura is an early danger signal Other warning 
signs are a fall-m the number of erythrocytes or white 
cells a fall m blood sugar level and a nse m icterus 
mdex During treatment the urine should be exam- 
ined at frequent mtervals for cells casts, albumin 
urobilinogen and sugar As the drug is a hver poison 
the diet should be nch m protective foods Inter- 
current infections hkely to throw an extra stram on 
the hver parenchyma would be a contraindication to 
treatment The possibility of bacilli developing resis- 
tance agamst thiacetazone has not yet been fully 
examined, but Auersbach and Schutz'^' believe that 
thiacetazone-resistant strains can occur These are 
then also resistant to other thiosemicarbazoncs In 
order to dimmish the toxicity of thiacetazone attempts 
have been made to combine it with other drugs The 
combmation of sulphathiazole and thiacetazone was 
highly toxic and has been abandoned Lepn and 
Capalbi^“ showed that m expenmental ocular tuber- 
culosis PAS and thiacetazone given together acted 
synergistically More recently Karlson and his col 
leagues” have suggested that streptomycin combined 
with thiacetazone is more active than either drug 
alone but ^Moeschlln and DemiraP" deny this and 
find the combination of streptomycm and PAS 
much more effective 

It IS obvious that, although streptomycm is far 
more active than thiacetazone. nevertheless the thio- 
semicarbazones are a group of compounds with un- 
doubted tuberculostatic properties Their true role 
m human tuberculosis can be indicated only by care- 
fully controlled mvestigations m which they are com- 
pared with streptomycin and with PAS The possi- 
bility of synergistic activity between these compounds 
and thiacetazone also requucs much fuller study 
In the meantime it may be noted that Ryne’* has 
obtained encouragmg results m 10 cases of leprosy 
after treatment for four months With doses of from 
50 to 150 mg of thiacetazone daily- there was no 
tendency to lepra fever, which is a danger with 
sulphones In addition the mental depression and 
slowing of cerebration so characteristic as effects of 
sulphone therapy were absent 


CONGENITAL MALFORMATIONS 
Pliny said that Nature creates monsters for the pur 
pose of astonishing us and amusing herself Up to 
quite recent times it was widely believed that congenital 
abnormalities were the result of impressions received 
by the mother during pregnancy Empedocles, Plato 
and Hippocrates all held that a severe fright dunng 
pregnancy might leave its imprmt on the unborn foetus * 


in n26 George I sent his chief surgeon to investigate 
the story of Sarah Toft, of Godaiming, who was said 
to have been delivered of 17 rabbits when five weeks 
pregnant she was alarmed by a rabbit which suddenly 
sprang up in front of her as she walked m a field 
In recent years a great deal has been learned about 
the aetiology of congenital anomalies Warkany,’ 
jvlurphy,’ and Kiskadden and his colleagues* have all 
I’eviewed the subject in detail Warkany described the 
experimental production of congenital deformities— 
juch as cleft palate, horseshoe kidney, eye defects, 
syndactyly, and other deformities of the skeleton— by i 
exposing the pregnant animal to gross vitamin A, nbo 
flavin, copper, or iodine deficiency, or to the noxious 
pction of various poisons, such as selenium, hthium, 
end X rays In a more recent paper Warkany and 
Wilson^ reported that^gross vitamin-A deficiency can 
eause cardiovascular anomalies, such as septal defect, 
end anomalies of the aortic arch 'and pulmonary artery 
Pypervitammosis A also causes abnormalities in develop- 
ing bone, as Mellanby* has shown m a report which 
■yenenJkij aipjeaneit m. *bjK, Vuw.'ial. In, aririifinn,, *hpxR. 's. 
evidence that skeletal abnormalities can be induced in 
developing chickens by the injection of insulm mto the 
yolk of (he eggs ’ Murphy’ discussed the genetic and 
statistical aspects of congenital deformities He states 
that the chance that any. couple will have defective 
offspring IS 1 in 200 The likelihood that a second mal 
formed child will be born to parents that have had one 
)S increased 20-25 fold The hazard of malformation 
jnereases with the age of the mother, rising progressively 
year by year after the mother has passed 30 The risk 
of congenital deformities of the foetus being caused by 
virus infections during pregnancy, particularly rubella, 
js now well known Anomalies of placentation, such as 
^ctopic pregnancy and placenta praevia, as a cause of 
deformities is also recognized ^ _ 

I Recently Record and McKeown® have brought new 
facts to light during a large-scale field study in Birming 
Jiam \ They chose congenital deformities of the central 
pervous system for study, partly because this group 
would be expected to provide adequate numbers^ for 
investigation, and partly because errors of diagnosis 
were unlikely They recorded observations on the aetio 
logy of 930 consecutive malformations of the nervous 
system which were the cause of stillbirth or first year 
death between 1940 and 1947 These constituted 059% 
pf the total births in the city in that period The types 
of malformation were hydrocephalus (150), spina bifida 
(389), anencephaly (366), and other defects (25) In 
^3% of the infants defects of other organs were also 
present The homes of the mothers of these children, 
and of those in a control group obtained by selecting 
pvery 200th name in the registers of live and still births 
for the same period, were visited by a team of investi ' 
gators It was found that the risk of a congenital 

1 Gordon B L. Romance of Medltme 1945 Philadelphia 

*/ 1 dvance tn Pedlitrlcs 1947 London vol 2 p I 

^Canzrntl {f Maffo •natlnnr 1947 Philadelphia 

• Int Abstr Su ? 1949 88 I 

“ Pedlnt 1950 S 708 

•P ithh Affdi al Jou nal 1950 2 535 

3 Duraiswami P K ibid 1950 2 384 

*Brit J roc Sfed 1949 3 183 

•Ib,d 1950 4 2fi ^ 

*9 Ibid 1950 4 in the press 



Jan 20, 1951 


CONGENITAL MALFORMATIONS 


Burma 

Medical Journal 


131 


deformity was considerably greater for the, first preg 
nancy and after the sixth There was no notable cor- 
relation between the incidence of defects and social 
circumstances, legitimacy, menstrual history spacmg of 
births, or fertihty There was little evidence of the 
importance of consanguinity The mcidence of mal- 
formations of the central nervous system m all siblmgs 
of a malformed foetus was 1 89%, and 2 77% m siblings 
bom after a malformed one Thus the risk that 
another malformed foetus might be born after the first 
one was about six times greater ‘than the risk for the 
general population (with an expected mcidence of 
045%) The hkehhood of another malformation 
seemed to be greater after the birth of a child 
with spma bifida than after other deformities The 
risk of recurrence of the same malformation was greater 
than that of a different one though the latter risk 
remained greater than the expected figure m the general 
population It IS to be hoped that the continued acquisi-\ 
tion of knowledge about the aetiology of congenital 
malformations will one day lead to their prevention 


FOWL PEST 

Whether or not any information applicable to the prob 
lems of human epidemiology can be learned from the 
study of Newcastle disease of fowls, the history of this 
virus infection is interesting The present serious epi 
demic m England has already necessitated the slaughter 
of thousands of btrds and there is a danger that the 
disease may become endemic as it hhs in America Eggs 
would then be scarcer than ever and poultry more expen- 
sive Newcastle disease, in its Asiatic form — which until 
the present outbreak has been the only type encountered 
In England — is an acute and highly infectious virus dis 
ease of birds to which domestic fowls are particularly 
susceptible The disease was first reported from the 
Dutch East Indies in 1926 and in the same year T M 
Doyle isolated the causative virus during an outbreak 
which occurred at Newcastle From the Far East the 
disease has spread predominantly westwards In 1928 
It was reported from India (as Ranikhet disease), in 1929 
from Japan, in 1930 from Ceylon and in 1931 from 
Australia, where it was known as ‘ pseudo poultry 
plague By 1937 it had reached East Africa and in 
1940 outbreaks were occurring in Palestine and Syria 
Soon It became widespread on the continent of Europe 
In England the first outbreak was at Newcastle in 
1926 there the epidemic spread rapidly through the 
adjacent counties and then burnt itself out The next 
was m 1933 at a large chicken farm at King s Langley 
in Hertfordshire the entire stock of some 10 000 birds 
was slaughtered and the epidemic was arrested England 
then remained free from the disease until after the war 
when poultry carcasses began again to be imported from 
Europe In 1947 there were 2 222 localized outbreaks 
It was the backyard flocks which suffered most — notably 
in the earlier outbreaks, those around London and the 
midland industrial towns where presumably imported 
carcasses were common For two thirds of these early 


outbreaks infected swill was either directly or indirectly 
responsible The import of infected carcasses from the 
Continent has continued, and not unnaturally so have 
the outbreaks of Newcastle disease Bemg of the acute 
Asiatic variety — the triad of peculiar respiratory symp 
toms green diarrhoea, and neurological signs is charac 
teristic — they have usually been easy to diagnose and, 
consequently to stamp out In the laboratory a doubt 
ful diagnosis can be confirmed either by the typical 
post mortem findings of which severe intestinal ulcera 
tion IS the most specific, by a reliable but technically 
difficult haemagglutination inhibition test on the serum 
or by isolation of the virus The serological test is 
particularly valuable the litre starts to rise six days 
after infection and has reached its maximum height by 
the ninth day The test then remains positive certainly 
for two years and possibly for life Thus a positive 
result does not necessarily mean that a bird is suffering 
from the disease at the time its blood is taken , it may 
indicate an old attack, and this may be useful evidence 
m tracing the origin of epidemicsx 

It IS the American type of Newcastle disease which 
now threatens the poultry industry in this country 
Although this was first described in America m 1940, 
and IS now thought to have existed there since 1935 the 
condition was not recognized to be immunologically 
identical with the Asiatic disease until 1944, when 
Beach compared American material with sera and virus 
received from this country Although the Amen 
can disease is highly fatal to chicks and very mfec 
tious, the symptoms are mild m the adult birds Out 
breaks are not, therefore, so easily recognized The 
present epidemic in England started last October on a 
farm at Mildenhall on which swill from a neighbour- 
ing U S Air Force station was used for feeding the 
chickens Since then there have been 118 separate out 
breaks of this low virulence disease, most of them m 
East Anglia, but some have occurred as far away as 
Lancashire and Kent Forty seven outbreaks have been 
traced to birds which were at the National Poultrj 
Show in December Nation wide extension of the dis 
ease is thus a serious possibility Unfortunately the 
chicks of the new hatching season are likely to fall easy 
victims to the disease 

The virus of Newcastle disease survives for only a few 
days outside the fowls body unless it is frozen, but 
while it IS living it remains highly infective, and can 
readily be transmitted by swill and by coops clothes, 
and other objects which have been in contact with 
affected birds Its short life outside the body accounts 
for the success of the policy of slaughtering, since 
infected ground rapidly becomes safe and recurrences 
m new stock from this source are practically unknown 
Unfortunately the resistance of the virus to freezing 
— It can survive for at least a year under normal 
conditions of refrigeration — makes nonsense of any 
attempts to control the import’ of the disease, 
whether of the Asiatic or of the American vaneties, 
except Jiy a total ban on foreign poultry — which mav 
well be necessary It is known, for instance, that among 
the food imported for American soldiers servmg in 



132 Jan 20, 1951 


FOWL PEST 


BRmsH 

MEDICAI, JOUKNAt 


Bntain have been frozen fowls, and it is reasonable to 
suppose that these may have been the cause of the 
present outbreak The part played by wild birds in the 
spread of the disease is not yet settled Outbreaks among 
poultry of crofters living in the Outer Hebrides have 
been traced to infected shag In America a starlmg 
and in Scotland a gannet have been found to harbour 
virus , and sea bird infection seems the most likely 
explanation of an outbreak among chickens kept by 
the Bass Rock light-house keeper Birds which have 
had the disease naturally are thought to acquire a life- 
long immunity 

Newcastle disease is notifiable, and the Minister of 
Agriculture has power to order the destruction of 
infected stock and to control the movement of poultry 
The difficulty in the present epidemic is one of recog 
mtion, but serum tests are being widely used If the 
policy of slaughter fails to stop the epidemic the only 
other remedy is vaccination, and this cannot be expected 
to be fully effective , its place is to moderate the disease 
once It has become endemic Newcastle disease Is, of 
course, primarily a disease of birds, but a severe con- 
junctivitis has been reported in pluckers and laboratory 
workers much exposed to the virus In these cases it is 
possible to recover the virus from the discharges from 
the eye but there are no serological changes and no 
immunity develops Whether the conjunctivitis is due 
to the virus or to the dusty atmosphere in which pluckers 
work may still be debatable, but the evidence so far 
would seem to favour a virus aetiology 


RELAXATION IN ANXIETY STATES 
The muscle relaxant mephenesin ( ‘ myanestn, ’ “ tol- 
serol ) was introduced to clinicians in this country by 
Berger and Bradley^ in 1947, and at the same tune 
Mallinson- pointed out its potential advantages in anaes- 
thetics These were then thought to be its non toxicity , 
Its rapid metabolism by the body so that all effect was 
lost within five hours , the quick results of intravenous 
injection , the satisfactory muscular relaxation which it 
caused , and its lack of effect on the respiratory centre 
, and on respiration Unlike curare, which has a some- 
what similar chnical effect, it does not act on the neuro- 
muscular junction but on the spinal cord Instead of 
leading, like curare, to a state of psychological dis- 
tress, It cau'ses, accordmg to Schlesinger, Drew, and 
Wood,’ ‘ a pleasurable relaxation,’ drowsiness, and mild 
euphoria Unfortunately later experience has not borne 
out all these claims, notably that of non-toxicify , 
increased fragility of the erythrocytes, possibly result- 
ing in dangerous anaemia * may be a consequence of 
Its administration Anaesthetists have now practically 
abandoned its use Another indication for the drug 
nearly as important as the one it had m anaesthetics is 
sUll under trial Mephenesin is absorbed from the 
stomach and may be given by mouth in tablet or liquid 
form It might therefore, be of value in the treatment 
of neurological diseases causing spasticity such as 
Parkmsons disease and disseminated sclerosis Unfor- 
tunately while it does prove of some help both with 


pyramidal and extra-pyramidal spasticity, so that it is 
at the present bme being quite widely employed, it is so 
rapidly destroyed in the body that m non toxic doses 
and when given by mouth it does not cause any large 
pr lasting effect in the severe cases which are in gfeatest 
need of relief 

Dixon and his colleagues are the authors of a recent 
report which suggests that mephenesin may have a useful 
application m psychiatry One of the commonest psy 
chiatric symptoms — almost always present in anxiety 
states and frequent also tn obsessional conditions, 
involutional depression, and even schizophrenia — is a 
state of tension, pamfully experienced as such subjec 
lively, and showmg itself bodily in increased autonomic 
tone, increased muscle tonus, tremor, and r/ther similar 
symptoms Dixon and his collaborators selected a group 
of such patients, who were physically healthy, actively 
at work, and mainly between the ages of 20 and 50 
Their complaints included dry mouth, gastro intestinal 
disturbances, headache, and early fatigue They were 
mostly found to have cold, sweating hands, dilated pupils 
and vascular hypertension Mephenesin was given as a 
chemical adjuvant to Jacobson’s well-known method of 
treating tension stales by traming m relaxation , with its 
help It was possible to show the patient what muscular 
relaxation could be, so that he could know what to aim 
at By taking the drug in a dose which varied between 
0 75 and 4 0 g , the patient was provided with one period 
of relaxation during the 24 hours, a period which did 
not as a rule last longer than two to three hours The 
authors obtained their best results with anxiety tension 
states, however chronic, and 47 out of 50 patients treated 
for this condition improved Rather less satisfactory 
results were obtamed with the much smaller number of 
patients in Vhom the tension arose on an obsessional 
basis, or who were regarded as 'pre schizophrenic or 
suffering from an involutional illness 

Although little has been heard about the psychia 
trie use of mephenesin in Britain, climcal expen 
ments are being made at one or two centres, and the 
provisional results conform with those of "the American 
authors But pleasant relaxation and mild euphoria are 
by no means always obtained, and some patients do' 
not tolerate the drug well As is the case with all other 
methods of treatment, the obsessional patient does not 
react so well as patients suffering from other functional 
conditions Nevertheless, the results which are obtained 
are sufficiently interesting for further chnical trial to be 
worth while Perhaps, as with other chemical discoveries, 
a pathway has been opened which will lead to better 
things Mephenesin is not a sedative in the ordinary 
sense and belongs to a different family chenucally from 
the other drugs used m both the neurological and the 
psychiatric disorders in which it may be indicated If 
mephenesm itself proves not -to be entirely satisfactory, 
perhaps one of its derivatives will be found to have a 
longer action and less toxic effect, and so come nearer 
to requirements 

V Zoned 1947 1 97 

»IWd 1947 1 9S 

‘Amrr J Med 1948 4 365 

*Ko5itchcl, R J and Barnet G S / Amer med Aie 1950 143 22 

‘Amer J med Sd 1950 220 23 



Jan 20, 1951 / 


TONStt-LECTOMY 


Bwtxsh 

Medical Jouwul 


133 


REFRESHER COURSE FOR GENERAL PRACTITIONERS 
PROS AND CONS OF TONSILLECTOMY 

t 

BY 

A H GALE, DM., DPH 

Director of Medico! Postgraduate Studies and Lecturer in Epidemiology Vnnersity of Bristol 


There are few subjects on which opinions are more 
divided than on that of tonsillectomy The differences of 
opinion are reflected in the bewildermg array of indi 
cations and contraindications for operation given in 
textboohs of otolaryngology and of paediatrics Gener- 
ally speaking the indications given are of two kinds 
those associated with purely local symptoms and signs 
and those associated with gereral conditions particu 
larly those in which Streptococcus pyogenes is believed 
to play an important part Some authorities lay stress 
on the local condition of the adenoids tonsils, and cer- 
vical glands, whereas others say that the local condition 
IS relatively unimportant and that the history of local 
infection or of general disease is the important matter 
in decidmg whether operation is necessary or not Some 
authorities advise the removal of adenoids alone, par- 
ticularly in young children, but it is doubtful whether, 
in actual practice this is often done 

Frequency of Tonsillectomy 
There is evidence that these differences of opinion 
have led to wide variations in practice For example, 
in the public schools nhich took part m the report on 
epidemics in schools* 60% of boys and 45% of girls 
had had their tonsils removed before they reached 
public school age, and in some schools the figure was 
as high as 80% These figures are for pre war years, 
but there is recent evidence to show that the rates are 
not very different now On the other hand, we find 
that in some of the great industnal cities less than 1% 
of the children at primary and secondary schools have 
their tonsils removed m a year which means allowing 
for those who are operated on before they go to school, 
that less than 20% of them will have had then: tonsils 
out by the time ftey teach the age of 15 In some of 
the south coast towns the operation rates approach those 
found in children of the social class who go to public 
schools Comprehensive reviews of tonsillectomy rates 
m different parts of the country hate shown that 
there can be no explanations of these great variations 
other than differences of medical opmion and, possibly, 
differences m the facilities atailable for performing 
operations 

When Should TonsiUectomies be Done* 

The problem of tonsillectomy has recently become 
even more complicated than it used to be because of 
the mcreased prevalence of poliomyelitis Formerly it 
was generally accepted that when the operation had 
been decided on it was better to get it done in the 
warmer weather, when streptococcal infections are at 
their lowest ebb, but the fact that the prevalence of 
poliomyehtis is highest in the summer and autumn has 
complicated the issue and the problem is now not only 
whether the operation should be done but when it should 
be done 

•Spec Rep Ser med Res Coim Land No 227 The report 
covers the jears 1932-34 inclusive and summarizes the expenence 
of 20 bo>s schools and 10 girls schools with an average popula 
Uon of 10 270 boys (8 287 boarders) and 3 503 girls (3 061 
boarders) A further report issued by the Medical Research 
Council No 271 covers the years 1935-39 


Docs Tonsillectomy do Any Good * 

In what follows something will be said about statisti- 
cal evidence because such evidence is objective and is 
relevant to the consideration of the general indications 
and contramdications of operation, but it must always 
be remembered that all the statistical evidence in the 
world, however carefully compiled, will not solve the 
problem m the individual case Whether a child should 
have his tonsils out, and when, is a clinical and not a 
statistical problem 

Evidence from Surveys 

Several large scale surveys have been undertaken in 
America and in this country m the attempt to decide 
how far tonsillectomy achieves the objects for which it 
IS done One of the best known of these is that of 
Kaiser, who followed up 4,400 children , half of these 
had had the operation and the other half, although 
recommended for operation, had, for vanous reasons, 
not been operated on Kaiser found that on the whole 
the relatively short term follow-up, after three years re i 
vealed greater advantages in the treated group than did 
the long term follow-up, after fen years He points out 
that this IS to be expected, smee older children are less 
liable to suffer from infections of the upper respiratory 
tract than are young children 
Kaiser found that the advantage of the treated group 
over the untreated group was most obvious when the 
child had a history of frequent attacks of tonsilhtis As 
a result of his survey he suggested the following as 
being defimte indications for operation (1) mterference 
with normal breathmg, snoring, etc , (2) difficulty m 
swallowing (3) nasal or altered voice , (4) persistent 
nasal discharge (5) impaired hearmg and otiUs media , 
(6) repeated attacks of tonsilhtis or qumsy , (7) enlarged 
cervichl glands (8) sinus trouble , (9) growmg pams or 
rheumatic fever , (10) pyelitis, nephritis , (11) unexplained 
malnutrition and anorexia , and (12) retarded mental 
development He considered that there was no advan- 
tage to the treateo group m respect of lung diseases 
It would probably be generally agreed now that some 
of Kaiser s recommendations went beyond his evidence 
and that many of his definite indications, particular!) 
those involving general diseases — for example. Nos 9-12 
— ^are at least very doubtful 
In this country the approach to the problem has 
been rather different, and attempts have been made to 
compare the incidence of certam conditions which are 
thought to have some association with tonsils and 
adenoids in groups of children who have been operated 
on and m groups who have not In the report on 
epideimcs in schools, which was concerned for the most 
part with children over 13 years of age, it was found 
that there was virtually no difference in the attack rates 
of nasopharyngeal infections, scarlet fever, rheumatism, 
appendicitis, otitis media (with or without mastoiditis), 
or pneumoma m the operated and unoperated groups 
During the course of the mquiry 364 boys had their 
tonsils removed, and in these cases the operaUon seemed 



134 Jan 20, 1951 


.TONSILLECTOMY 


Bunsq 

Medical Jouhmal 


to reduce the amount of school time lost through illness 
This section of the report ends with the words ‘ One 
cannot avoid the conclusion that there is a tendency for 
the operation to be performed as a routine prophylactic 
ritual for no particular reason and with no particular 
result ” 

In a more recent but less comprehensive follow-up of 
337 children operated upon at the Radcliffe Infirmary, 
Oxford, in the years 1947 and 1948 it was found that 
operation reduced liability to sore throats and to colds, 
but the bther findings were more uncertain, although 
there was a suggestion that the relatively small number 
of children who had ear disease before operation were 
improved after operation It should be noted that most 
other authorities seem to be doubtful whether the fre 
quency of colds is reduced by operation 
In spite of the very large number of figures published 
a really convincing statistical examination of the effects 
of tonsillectomy has yet to be made It would not be at 
all easy to plan such a survey, but the Oxford inquiry 
gives an outhne of a method which might be adopted 

Clinical Opinion ' 

As has been said above, the recommendations of those 
whose views are entitled to respect, because of their wide 
experience, differ considerably and are extremely dififi 
cult to summarize There are, however, certain recom 
mendationS which seem to be generally accepted * 

1 Tonsils should very rarely be removed before the age 
of 5 Adenoids should be removed at any age if they ate 
causing nasal or Eustachian obstruction It must be reroem 
bered that there are common causes of nasal obstruction 
other than adenoids 

2 The operation should not be performed on a child 
who has never had symptoms whatever may be the appear- 
ance of the tonsils Their appearance varies enormously m 
the same child at different times 

3 Tonsils should be removed on account of frequent 
attacks of tonsiUitis with fever Ttue^totisilWis should be 
distinguished from the transient sore throat which often 
precedes the development of a cold in the head The exact 
number of attacks in a year which should be regarded aS 
significant is disputed — some would say two some three or 
four It IS perhaps more important to consider the degree 
of general disturbance — temperature and duration — rather 
than the exact number of the attacks In this connexion it 
IS misleading to think only of sore throats because a child 
may have a quite severe degree of general disiurbance due 
to tonsillitis without complaining much of sore throat 

4 Tonsils should be removed at a suitable interval after 
a quinsy 

5 Tonsils should be removed in the very rare instances 
when they are so large that they cause mechanical 
obstruction 

6 Tonsils should be removed in chronic diphthena carriers 
when other treatment has failed 

These ate the indications which would be generally 
accepted and it remains to discuss the very difficult 
subject of disputed indications 

Disputed Indications for Tonsillectomy 
Genernl Diseases 

Tonsillectomy has at some time been recommended 
for almost esery disease of children and for many con 
ditions such as mental retardation or enuresis which can 
hardly be called diseases Probably no one now believes 

•The recommendations listed arc based largely on opinions 

f isen et a discussion ai the Royal Soaety of Medicine (Proc R 
oc hUd 1950 43 317) 


that tonsillectomy has any influence on general dis 
eases other than those which appear to have some asso 
ciation with infection of the throat by Sn pyogenes, 
and for practical purposes these may be jeduced to 
juvenile rheumatism and nephritis There i^ little doubt 
that when a first attack or a relapse of acute rheumatism 
occurs It has often been preceded by an attack of tonsil 
htis occurring about three weeks before, and the rela 
tion between tonsillitis and nephritis is similar In these 
cases It IS probably wise to apply the same criteria m 
deciding the need for operation as those suggested above 
for children m general It must be remembered, how 
ever, that operation may have the same effect as an 
attack of tonsillitis in precipitating an attack of 
rheumatism or nephritis Operation should therefore 
be done only when the disease has been quiescent for 
some months, and under full cover of pemciUin 

^ j 

1 

Enlniged Cervical Glands 

This condition is so common in children and there are 
so many causes for it that it is not a veTy_ useful guide 
to decision Sometimes, however. Sir pyogenes seems 
to leave th6 tonsils almost unscathed and to attack the 
glands directly Admittedly it seems illogical to suggest 
that when this process happens repeatedly it is an indi 
cation for operation but I believe that it is This type 
of occurrence is probably 'really an example of tonsillitis 
without much ‘ sore throat ” ^ 

Risks of Operation 

The operation has a small but quite definite mortality 
No one knows exactly what it is because the total 
number of operations performed in a year is not known, 
,nor IS it possible to determine the exact number of 
deaths properly attributable to the operation It seems 
likely however, that about 80 deaths a year occur as 
a direct result of the operation 
The possibility of throat infections or even of septi 
caemia following operation has heen mentioned above 
With adequate precautions it should be possible to avoid 
this risk , 

TonsiDccloiny and Polioniyditis 
The possibility which has undoubtedly aroused the 
greatest anxiety recently is that of an association between 
operation and poliomyelitis As in the surveys on the 
effects of operation, vast arrays of figures have been 
amassed by both sides in this controversy Unfortunately 
most of these figures are unconvincing 
But a more important matter is that of the possible 
association between tonsillectomy and poliomyelitis of 
severe biilbar type Everyone has heard of the five chil 
dren of one family in Akron Ohio, who had their tonsils 
removed in August, 1941, and all developed bulbar polio 
myelitis, of which three died The sixth and youngest 
child, who was not operated upon, did not develop 
poliomyelitis, although excreting poliomyelitis virus in 
the faeces 

In a nation wide survey of cases of poliomyelitis 
treated in hospitals in this country m 1949, 16 cases of 
poliomyelitis were reported as having followed within 
one month of an operation for tonsillectomy Of these, 
four died (two were brothers) of bulbar poliomyelitis, 
four had bulbar signs and recovered, seven had the 
spinal type of disease and recovered, and one had no 
paralysis Admittedly the risk of a patients' develop- 
ing bulbar pohomyehtis after tonsillectomy is a remote 



Jan 20, 1951 


TONSILLECTOMY 


Bjuiuu 

MOICaI. JOUHNAl. 


135 


one, but it is so tragic a possibility that few people would 
knowingly allow their children to run it We know that 
at certain times and in certain places the virus of polio 
myeUtis is widely distributed among the population 
and, when it is, tonsillectomies should be discontinued 
altogether or at any rate confined to those cases m which 
the operation is really a matter of urgency 

Conclusion 

The decision whether tonsillectomj is necessary or not 
IS by no means an easy one and both the general prac- 
titioner and the laryngologist have a contnbution to 
make to it The general practitioner knows how often 
the child has had tonsillitis and how ill he has been with 
It, and the laryngologist is in the best position to evalu 
ate symptoms of nasal and Eustachian obstruction and 
to consider how far the child s symptoms may be due 
to a chronic sinusitis Generally speaking it is better 
to delay decision than to hurry it, and above all to avoid 
operation on tonsils which have been recently inflamed 


ORDER OF ST JOHN OF JERUSALEM 

The London Gazette has announced the following promo ‘ 
tions in and appointments to the Venerable Order of the 
Hospital of St John of Jerusalem 
As Knights Drs Enk Hoerman and C Gardiner HiU As 
Commanaers (Brothers) Colonel K B Fraser M B Drs E P 
Scott R V S Cooper W B Fox J R Hanna CSC Prance 
D J Nicol N S B Vmter and E M Humphery As Associate 
Commander (Brother) Major S K Engineer O B E 
F R C P Ed As Officers (Brothers) Drs S I A Laidlaw B 
LaHaye C H Vernon B L Steele C E H Gaier H E 
Thomas and L G Norman As Associate Officers (Brothers) 
Lieutenant Colonel P M Petigara M B and Drs B B Rai and 
K B M S Mahmood As Officer (Sister) Dr Ella P Hopgood 
As Associate Officer (Sister) Dr Rose Baranov As Serxtng 
Brothers Colonels R J M Home M B and J F O Grady 
MB T D D L Majors W C Lowry M B E M D and R 
Rutherford M P RA M C Drs M A Foulis J L du Preez 
L F C Berlinguet L M Hanna J A Melanson G Racicot 
J Robertson A Turner G S Mather J E S Hamilton A 
Morrison T Staines Read N MacLeod C B Ball M B E 
S G Nelson G J Duncan J R Thompson F F Heddle 
E C Pope and I O Thorbura As Associate Sening Brother 
Dr P K K E Raja As Serxing Sisters Drs Joan B 
Landsman Margherila M Freeman Janet P Cooper .and Jane 
M Adam ' 


In a recent issue of the Canadian Journal of Public Health 
Sir James Stirling Ross draws attention to a passage in 
Anstotle s Rhetoric (Book 1 Chapter 5) which discusses 
happiness (eu^aip.ovta,eudaemonia) health (6Y(eia hygieia) 
and well being in old age (euyTjpia, eugena) and says 
of the last named in Sir James s rough translation 
Eugena may be defined as slowness in the oncome of old 
age with freedom from pain You cannot call a man happy 
in his old age either if he ages quickly or if he ages slowly 
but with pain Eugena comes from the virtues of the body 
and from good fortune A man may be free from diseases 
and enjo> physical strength and yet not be free from suffer 
ing pain and without good fortune a man could not reach 
to an old age There is also a certain power of long life 
apart from strength and good health for many men arc 
long li\ed without the Mrtues of the body But a high pre 
cision in these matters is out of place in this discussion 
Sir James suggests that the word geriatrics now in vogue 
although without an> classical authonty should be dropped 
in fa\our of the use of eucena which is also more 
euphonious and expresses well the meaning of ageing 
successfulh Geriatrics means the heahng of old age but 
of course the doctors job is not to heal old age for it is no 
disease but to protect it from going awr> " 


Reports of Societies 


VAGINAL DISCHARGE 

At a meeting of the Devon and Exeter Medico Chirurgical 
Society held on December 21 1950 Dr Margaret Hadley 
Jackson gave an address on vaginal discharge 

Dr Jackson said that some degree of discharge from the 
vagina was normal though the character of the discharge 
varied according to the age of the woman Thus micro 
scopical examination permitted the recognition of infantile 
mature (during the child beanng years) and post menopausal 
(semle) types In the mature tjpe three distinct groups 
could be distinguished by their charactenstic flora each of 
which was commonly encountered and tended to be fairly 
constant in any particular individual When confronted 
with a case of vaginal discharge it was useful to attempt 
to classify it as physiological due to hormonal imbalance 
or pathological 

Among infants and children whose vaginal mucosa was 
thin the commonest cause of ■discharge was vagimtis either 
traumatic from foreign bodies or masturbation or infective 
due to the gonococcus or other organisms In the mature 
woman other traumatic causes had to be borne in mind 
such as nngs menstrual tampons or buned sutures after 
penneal repair In addition one had to consider the possi 
bility of allergic reactions to contraceptives of infestation 
with tnchoraonas or yeasts (the latter particularly in preg 
nancy and diabetes melhtus) of venereal disease of cervical 
and utenne lesions and of fistulae into the bladder or 
rectum In the post menopausal woman m whom the mucosa 
had again become thm in addition to discharges due to 
polyps or mahgnant disease one encountered an atrophic 
vaginitis often charactenzed by a profuse and offensive dis 
charge but with trichomonas and momha almost mvanably 
absent 

The history was of the first importance Was there imta 
tion soreness dysuna or bleeding ’’ Had there been a venereal 
contact’ The source of the discharge had to bj located 
the unne tested and threadworms and piles excluded The 
macroscopic appearance of the discharge was often charac 
tensile To examine the discharge microscopically a speci 
men should be collecled from the formces with a long 
handled bakehte spoon and a' wet film made Elaborate 
methods of illumination or staining were not essential in the 
ma)onty of cases or unless venereal disease was suspected 

Tnchomonal Infestation 

Treatment must be appropnate to the cause that of tncho 
monal and mondial infestations being sometimes tedious 
Dr Jackson advocated ringing the changes on two or more 
methods of treatment in cases of tnchomonal mfestation — 
e g picragol powder acetarsol tablets or carbarsone 
suppositones combined with douchmg with hypochlonte 
solutions (as in vetennary practice) or with lactic acid — and 
in cases where the mucosa was thin and most particularly 
in the young the use of oeslrogens either locally or orally 
Where the husband was also mfected with tnchomonas the 
wife was constantly subject to reinfection however the 
treatment of the male was extremely difficult 

Out of a senes of 468 women attending the Whitechapel 
Clinic 232 had been found to be mfested with tnchomonas 
of these 102 also had gonorrhoea In a series of infertile 
women attending the Exeter and Distnct Women s Welfare 
Association clinic the incidence of tnchomonal mfestation 
was 15% while in a birth-control senes at the same climc 
It was only 5% This lent support to the view that chemical 
contraceptives had a deterrent effect on tnchomonas 

For the treatment of mondial infestation Dr Jackson 
recommended alkaline douches and the use of a gentian- 
violet-gljcenn and borax suppository for vaginitis m the 
very young oestrogens by mouth or locally were un 
doubtedly of value Non specific cervical discharges yielded 
dramatically to treatment «i!h the electnc cautery together 
with sulphonamides by mouth or pemcillm by mjeetion 



136 Jan 20, 1951 


CORRESPONDENCE 


/ 

Burma 

Medical Journal 


Correspondence 


Appendicitis in the Navy 

Sir — I would like to ask Sir Cecil Wakeley in his capacity 
of senior consultant surgeon to the Royal Navy, if his state 
meat (December 16 1950, p 1352) ‘ There is no place for 
expectant treatment applies to single handed ship doctors 
who are not ‘ surgical specialists ’ Some thirty years ago 
various comparative senes of appendicitis statistics could 
show no definitely significant differences between immedi 
ate operation and expectant treatment, as regards case 
fitahty' in well looked after hospital cases under the best 
surgical environment Therefore being no surgeon, I always 
practised expectant treatment at sea and advised others in 
like circumstances to do so I hasten to add that as Medical 
Director General I never issued personally any orders on 
surgical treatment though as M D G I did discontinue the 
practice of congratulating those zealous young doctors who 
removed appendices at sea with the assistance of the purser 
and chief engineer always, for some obscure reason in a 
raging gale I deprecate also the far too prevalent habit 
(it may be a belief) of allowing patients to believe that only 
an immediate operation can save their life if suffering from 
appendicitis 

The pomt 1 raise is important for, though in my long 
expenence I recollect no serious disaster following either 
immediate operation or a policy of ‘ wait and see ’ in the 
treatment of appendicitis afloat there is no definite ruling in 
the matter There is certainly a school of young naval 
medical officers whose one desire is to remove appendices 
afloat , but I believe but am not certain, that the expectant 
treatment is far commoner in small ships with no adequate 
surgical amenities It would be valuable therefore to have 
Sir Ceal Wakeley s ruling on this subject He understands 
(he conditions and knows the surgical capabilities of the 
naval doctor better than I do In his great zeal for improv 
mg naval surgery Sir Cecil may actually have some figures on 
the treatment of appendicectomy at sea — I am etc, 

Leamlmion Spa Sheldon F Dudley 

Surgeon Vice-Admiral Ret 


Appendicitis 

Sir — I n the article by Sir Cecil Wakeley and Mr Peter 
Childs (December 16 1950 p 1347) and in the subsequent 
correspondence (January 6 p 36) it is clear that successful 
treatment of the acute case depends more than anything else 
(sulphonamides penicillin, etc ) on early diagnosis and early 
appendicectomy with the minimum of trauma In the late 
case particularly where there is a palpable appendix abscess 
I agree with Mr McNeill Love that there is a place for 
conservatism, provided the patient is under competent super 
vision and is repeatedly and carefully exammed 

It IS not enough to stand at the foot of the bed and study only 
the hourly temperature and pulse record the abdomen should be 
frequeutiy exammed Undue reliance on the temperature and 
pulse rate as diagnosUc or even prognostic signs is a delusion 
and a snare Most expenenced surgeons have removed gangren 
ous and acutely obstructed appendices from patients who have 
walked into hospital with a normal temperature and puke In 
many cases especially m the obstrucuve type of acute appendicitis 
a nsc of temperiture and puke rate follows rather than precedes 
perforation of the appendix I beheve and have always taught 
that many more carl> and accurate diagnoses with a consequent 
drop m mortalu> would result if the temperature and puke rate 
were completely ignored I have known many practitioners who 
waned for a nse in pulse rate before diagnosing acute appendicitis 
The ma;ont> of their cases had perforated before being adimtted 
to hospital 

The obstructed appendix situated in the pelvis (generally in the 
astheme ty^pe of patient) is usually diagnosed late for the simple 
reason that a rectal examination has not been made It is now 


generally recognized that pain evoked in the appendix will be 
situated m the umbilical region central because that is the early 
embryonic position of the appendix and the position it occupied 
when Its innervation was acquired The appendix has a bilateral 
innervation whereas all bilateral organs have a unilateral innerva 
lion therefore there should be no difficulty m diagnosing pain 
producing disorders m the kidneys or ovanes Pam produced m 
a kidney is always unilateral But m some cases of appendicitis 
there is no central pain InUhe mild inflammatory type only 
local tenderness and, later, local pain will be present, the reason 
being that the threshold for intestinal pain is higher than that 
for pain produced m the parietal pentoneum Again perfora 
tion of an appendicular diverticulum will give nse to sudden acute 
local pain as does perforation of a duodenal ulcer 

Mr J A Ross s letter (January 6 p 36) deals with what 
IS generally described as the ‘ lethal dose of castor oil 
Surely it is not so much the action of the aperient which 
precipitates disaster as the delay which ensues to see the 
result Many thousands of appendices^have perforated in 
patients who have had no castor oil In most if not in all 
perforation wouljl b'e the inevitable result of the pathological 
condition present if operation is deferred, and whether or pot 
an aperient is administered 

The decision regarding the site of the incision and the subse 
quent steps of the operation should be made after due considera 
tion of the situation of the appendix, its pathological condition 
and the build of the patient (a point seldom considered) The 
surgeon should remember that m the thm visceroptotic patient 
adequate access is easy, that the mesenteries arc relatively long 
and that the caecum and appendix will probably be situated low 
in the abdomen or even in the pelvis In the stout sthenic indi 
vidual the mesenteries are short, the caecum is probably sessile 
and situated high m the iliac fossa In these latter cases a 
high gridiron incision (or a Rutherford Monson mcision) will give 
much better access and wilT result m a much easier operation, 
for both surgeon and paUent, than a paramedian mcision 

The surgeon who says, I always use this incision/ has 
little imagination and has learned little from expenence, and 
sooner or later will find himself in an avoidable difficulty 
As Mr R Strang (January 6 p 36) wisely indicates, adequate 
access (in all operations), and not the small pretty scar, is 
the primary consideration if the best results are to be 
ensured — I am, etc , 

Dundee F R Brown 

Smallpox and Human Sacrifice 

Sir — I am one of the medical officers of. health acutely 
concerned with the movements of the original patient in 
the Brighton outbreak of smallpox and should hke the 
courtesy of your columns for making pubhc certain 
observaiiODs 

With the increasing frequency of air travel, we are apparently 
unable to keep smallpox out of the country It is possible to 
meet a man m the street, or train or bus who was on the 
other side of the world only a few days before, and who is to 
say that he is not carrying the Misease, modifled or otherwise ? 
We fear the importation of smallpox because all tpo often some 
body has to die before the importation is recognized And then 
the pubhc goes into a flat spin demanding mass vaccination over 
a Wide area to the detnment of the normal work of hospitals 
general practitioners and health departments The tragedy is that 
not one of these deaths is necessary but apparently we still roust 
have OUT human sacrifices so that the general pubhc can go 
unvaccinated It is of course no more than justice that the 
sacrifices should be drawn from the great unvacemated Infant 
vaccination confers some degree of protection for a great many 
years Deaths from smallpox very seldom occur after successful 
infant vaccination Similarly infant vacanation is fraught with 
little danger from post vaccinal encephaUtis and protects agamst 
the occurrence of this condition after secondary vaccination It 
IS therefore gross negligence on the part of parents to omit to 
have their children vaccinated m the first year of life If this 
practice was universally carried out it would take only a few 
years to build up the community s resistance so that death from 
smallpox became impossible Fear of the disease would con 
sequently depart In the meantime steps must be taken to 
compel the reporting by anyone entenng the country of any iH 
ness whatever which occurs within three weeks of entry 
Similarly the onus of reportmg should he on any doctor 


Jan 20, 1951 


CORRESPONDENCE 


Bxmsa 

^b3)iCAL JOUWUL 


137 


encountenng such a case Failure on the part of the Government 
to take immediate steps to enforce such a requirement would also 
be gross neghgencc 

There is nothing especially new in the views put forward 
but It docs seem to take a long time for elementary facts to 
penetrate the pubhc consciousness — 1 am etc 

Eiirfn I C Monro 

Treatment of Barbiturate Poisoning 
Sir — In a recent letter (December 9 1950 p 1333) Dr H 
Creditor suggests that amphetamine sulphate is the drug 
of choice for acute barbiturate poisoning It is not made 
clear on what clinical or experimental evidence this sugges 
tion IS based In the more severe cases of acute barbiturate 
poisoning the respiratory centre is markedly depressed and 
this depression may rapidly prove fatal In animal studies 
amphetamine sulphate has proved a feeble stimulant to the 
respiratory centre and clinical observation has not suggested 
any stimulant action in humans Picrotoxin on the other 
hand has a powerful action m combating the respiratory 
depression of acute barbiturate poisoning la my article 
(October 21 1950 p 924) I stated that intravenous 

amphetamine sulphate is a useful ancillary drug m the treat 
ment of acute barbiturate poisoning In severe cases it 

IS of little value m the early stages but may shorten the dura 
Won of coma if given later I am not influenced by Riishede s 
report of the treatment of 132 cases of barbiturate poisoning 
with amphetamine (^Lancet December 16 1950 p 7S9) He 
used the drug to supplement various general measures and 
on account of a lower mortality in comparison with a 
previous senes treated with nikethamide suggested that 
amphetamine was a satisfactory cerebral and circulatory 
stimulant His report makes scant reference to the import 
ance of respiratory depression as the cause of early death m 
these patients 

The proper treatment of this condition must be based on 
an understanding of the pharmacological and pathological 
properties of the drugs concerned Barbiturate poisoning 
may be rapidly fatal through respiratory depression or pro 
longed coma may lead to fatal bronchopneumoma Deaths 
from the latter are reduced by nursing care prophylactic 
antibiotic therapy and attention to fluid balance and 
amphetamine on account of its powerful awakening action 
may shorten the duration of coma and hence reduce the 
dangers involved The severe cases in which respiration is 
slowed and the patient cyanosed call for urgent measures 
to combat respiratory depression A mechanical respirator 
or phrenic nerve stimulation may be used in the most desper 
ate cases and picrotoxm is valuable as a stimulant of the 
respiratory centre Amphetamine is useless under these 
circumstances and its routine admimstration to alt cases 
regardless of the cliiucal condiuon will lead only to 
unnecessary loss of life — I am etc 
London W C 1 J D N NaBARRO 

Mcthjlene blue Test of Ice cream 
Sir — It would be unfortunate if your annotation 
(December 23 1950 p 1431) should give the impression tlrat 
the methj lene blue lest forms a satisfactory basis for the 
grading of ice cream The report [Mon Bull Mm Hlth 
I9S0 9 231) nghtly points out the limitations of the 44 C 
coliform test stating that only a few of the organisms isolated 
were found to be faecal coliforms (48 faecal of 676 presump 
rive) This reasoning applies with greater force to the 
methvlene blue test taken alone since this is positive in the 
presence of sufficient numbers not only of coliforms and 
faecal streptococci but also of spore bearing aerobes 
It IS possible during the course of manufacture to eliminate 
all tvpcs of coliforms but the non pathogenic spore bearers 
are frequently present m the raw matenals supplied to manu 
faclurers and are unaffected by any form of heat treatment 
which could be applied to ice-crcam. There is no justiflea 
tion for your statement that the aerobe spore bearers are 
a potential cause of food poisoning. 


The 17 hour methylene blue test is open to even greater 
objection It is argued that it indicates latent contamination 
This IS totally misleading since spores of certain aerobes 
isolated from commercial samples of ice cream when added 
to the autoclaved ice cream as a medium and allowed to 
stand for 17 hours at 20 C will cause failure of the test 
within the four hours even though the number added be 
only two viable spores Moreover the test is an unfair one 
since there is no risk of anyone eating ice cream which has 
been melted for 17 hours A test which can give a positive 
result in the absence of intestinal organisms and a negative 
result in tbeir presence can never be taken as the sole 
standard of merit of any food product however convenient 
it may be for the laboratory 

The methylene blue test is at best a good screening test for 
the degree of contamination of a sample but it can be no 
substitution for the isolation and identification of the 
organisms present — I am etc ' 

looeon w 13 W Howard Hughes 

Health, Diet, Soil 

Sir — I was very interested to read the account (December 
2 1950 p 1272) of Sir Lionel Whitby s lecture Can Disease 
be Prevented ’ Great advances have certainly been made 
in the field of preventive medicine but one wonders why so 
little attention has been paid to the factor of diet in disease 
prevention Sir Robert McCamson gave conclusive proof 
that food IS a very important factor m health and disease 
and Sir Albert Howard went further and showed that not 
only the food itself but the way in which it is grown (or in 
other words the condition of the soil) could make all the 
difference between health and disease m livestock By 
increasing the fertility of his soil by banning artificial 
fertilizers and usmg only compost made from animal and 
vegetable wastes he was able to build up the health of his 
animals to such an extent that they did not become ill He 
says m one of his books that he has often seen his cattle 
(in India) rubbing noses over the fence with cattle suffering 
from foot and mouth disease — but his cattle never took the 
infection He pointed out that tnbes such as the Hunza 
who live on the whole foods grown on composted soil enjoy 
great health and vigour and show considerable immunity to 
disease 

For some years now I have been advocating a whole food 
diet With compost used m the kitchen garden when possible 
and have found that all who adopt this improve in health 
and vigour I used to suffer from frequent colds and chrome 
catarrh but have found that these have just vanished since 
following this way of feeding At the age of 45 I can work 
long hours and never feel tired I would suggest that doctors 
who are interested should try this way of life on themselves 
and their families They will find an improvement m their 
health withm a very short time — I am etc 

Toobndsc Wdli Kent HECTOR W JORDAN 

Congenital Deformities 

Sir — 1 read with interest Mr G C Gordons letter 
(December 30 1950 p 1495) I must admit I do not know 
anything about his views on the causation of congenital 
deformities in humans so I will await the publication of the 
paper referred to in his letter with keen interest In the 
meantime I would like to answer one or two points arising 
from his letter 

In the first place I have not made any suggestion in my paper 
in the Journal (August 12 1950 p 384) that certain human 
skeletal abnormalities may also be caused by msuhn though 
according to Oakley and Peel (1949)' the incidence of congenital 
abnorinalmes m children bora to diabetic molhers who were 
'ptesomably treated with insulin dunng pregnancy was as high as 
63% compared with a general incidence of 0 94% dunng the 
same penod It is however not clear whether these congemta! 
dcfortmties are caused by maternal hyperglycaemia and ketosis 
due to diabetes meilitus or foetal hypoglycaerma which may be 
cau5^ by the injections of msulm given to the mother dunng 
pregnancy or by excessive secretion of insulin by the hyper 
trophied islets of Langerhans of the foetus It will be mtefestmg 



138 Jan 20, 1951 


CORRESPONDENCE 


BMtisa 

Medical Joiddol 


to know whether such a high incidence of congenital abnormal! 
ties has been notieed in children born to mothers who suffer from 
hypoglycaemia dunng pregnancy due to orgamc hyper 
msulinism or other causes 

Secondly according to Ingalls of the Harvard School of Public 
Health, the implication of the valuable epidemiological observa 
tions made in recent years regarding rubella mongohsm,’ 
encephalo ophthalmic dysplasia * oesophageal atresia, and tracheo 
oesophageal fistula* is that the principles which govern the 
disturbances of growth and differentiation in lower animals can 
be applied also to human developmental arrests and malforma 
tions Gregg* says I regard rubella and its sequelae as the 
title of but one chapter m the full story of congemtal defects 
many more chapters have yet to be written ’ 

Mall, after a lifetime mvestigation of the pathology of the 
human embryo concluded that in the causation of human con 
genital malformations ‘ faults m the environment are chiefly 
to blame Since very httle is known of the detailed histology 
of the early human embryo the histological examination of cases 
of perverted growth and differentiation is mainly hnuted to those 
abortions and stillborn infants which, not infrequently tend to 
present vary mg degrees of post mortem degeneration before 
accurate histological methods can be applied It is here that 
experimental research can offer invaluable help and according to 
Mall the pathological changes induced m human embryos by 
environmental disturbances and those obtained experimentally 
in animals are not analogous or sirmlar, but identical ’ 


I intend to send for publication a more detailed paper on 
the experimental causation of congenital defects in chickens 
bv synthalin sulphonamide compounds thallium salts 
and 3 acetyl pyridine, and its significance in orthopaedic 
surgery and I hope it will give further support to the above 
mentioned observations In my preliminary paper published 
m the Journal I could not give a review of the work done on 
experimental teratogenesis, but I hope to include it m my 
next paper — I am etc 

Liverpool P K DuRAtSWAMI 


,, REFSttSNCES 

* Oaklev W and Peel J fI949) Quoted by F J Browne m Poir gfadi/ottf 

Obstetrics and Gynaecolosy t950 p 405 iLondon Butterwortb andCo 
•Ingalls T H (1947) Amer J Dis Child 74 147 

* (1948) Pediatrics 1 315 

i and Pnndle R A (1949) New Engl I Med 240 987 

; Gregg N McA (1945) Med J Aust 1 313 
«Mall,F P (1917) ,4mer J Anat 22 69 


Death from Exsangumo-transfusion 

Sir — T he letter of Drs P D Bedford and L G Lajtha 
(January 6, p 38) in which a biochemical death after 
exsanguine transfusion in a case of acute monocytic leuk 
aemia is described deals with so important a subject that it 
IS to be hoped that they will publish their observations in 
detail 

I think that the amount of blood they gave (19 6 litres) is the 
largest amount that has ever been given at one session and it 
would be interesting to know at what stage the first symptoms of 
tetany developed The largest volume I have used at a session 
was about 25 pmts (14 htres) 20 bemg ordmaiy blood from the 
bank while five consisted of packed corpuscles At no time did 
any signs of tetany manifest themselves 
Another matter on which further information is essential is 
why so large an amount was given at one time In the earliest 
days of exsanguino transfusion for acute leukaemia it was 
supposed that any benefit that arose was due to withdrawal of 
noxious substances in leukaemic blood and simple replacement by 
blood of better quahty The theory has undergone a good deal 
of modification and it is now usual to suppose that exsangumo 
transfusion acts in several ways It results m withdrawal of 
enormous numbers of leukaemic cells and of much plasma which 
may perhaps contam some noxious substance and it also supphes 
more or less normal plasma m which there may be either a sub 
stance required for the maturation of leukaemic cells or one 
which inhibits their prohferation Certainly it is I think 
accepted that any good results that ensue are not due to simple 
replacement of blood or to lavage of the marrow by normal 
blood If this be accepted there would seem to be every reason 
for anticipating better results from repeated partial exsangumo 
transfusions than from a single more or less complete one My 
own experience and the more recent hterature of the subject 
seem to support this view 

Lest It be thought that I am an advocate of exsanguino 
transfusion in the treatment of acute leukaerma 1 should hke 
to say that in my opimon the operation whether at one 


sitting or in repeated sessions should never be earned out 
unless the patient or some responsible relation clearly under 
stands that at the best a remission of a Very few months 
may be obtained It is now clear that the procedure does 
not cure acute leukaemia' and indeed the proportion of 
cases in which remission occurs is small about 20% which 
IS almost exactly the same proportion as m cases treated with 
aminopterin or A C T H 

It must alsOjbe remembered that repeated simple transfu 
sions without concomitant exsanguination, are sometimes 
followed by more or less complete remission For example 
Andrd has recorded a case m which a remission following 
this procedure (2 due to it) lasted for three years and seven 
months the relapse that ensued was not influenced by 
further transfusions 

' I feel sure that Drs Bedford and Lajtha are acquainted 
with Dreyfus s critical review of all the published cases of 
remissions of acute leukaemia but those less versed in 
haematological literature will find his reasoned discussion a 
salutary antidote to undue optimism — 1 am etc 
London W 1 A PiNEY 

References 

Andrf A (1950) Sang 21 833 
Dreyfus B (1948) Jtey Hdmat 3 29 


Metabolic Effects of Salicylate 

Sir — The article of J B Cochran, R D Watson, and J 
Reid (December 23 1950, p 1411) intensifies the confusion 
created bv previous papers (Reid 1948 Reid el al 1950) 
concerning the effects of salicylates on the body acid base 
balance In this last communication the authors state that 
salicylate produces a respiratory alkalosis, and then go on to 
say 

Large doses of salicylate lead to accumulation of the drug m 
the plasma, displacement of equivalent amounts of bicarbonate 
and a raised plasma pH As plasma pH depends on the 
ratio HjCO, NaHCO, any reduciton in bicarbonate must be 
accompanied by an equivalent reduction in the concentrations of 
plasma I})CO, This may be achieved by mcreasing alveolar 
volume which lowers alveolar CO^ concentrauon and therefore 
plasma H^CO, The chmeal counterpart of this physiological 
adjustment is the slow deep breathmg on salicylate admmistra 
tion ’ (my itahcs) 

Thus having admitted that salicylate produces a respiratory 
alkalosis they ascribe the physiological adjustments to a 
metabolic acidosis, repeating the mistake of Reid (1948) 
Elsewhere (Rejd el al 1950) they agree that the primary 
effect IS on the respiratory mechanism , and their published 
data disprove the present suggestion that sahcylate displaces 
eqmvalent amounts of bicarbonate 

The actual disturbance of acid base balance produced by 
salicylate was shown tovbe a respiratory alkalosis by Guest 
and Rapoport (1942 1945a 1945b) and the probable reflex 
origin of the hyperventilation was indicated by the observa 
tions of Graham and Parker (1948) Carbon dioxide loss in 
primary and subsequent adjustment of the plasma HCO, 
level IS mainly dependent on renal mechanisms In healthy 
subjects the kidney responds to an acute respiratory alkalosis 
by the excretion of large amounts of sodium and potassium 
bicarbonate (Stanbury and Thomson, 1951) a response which 
if contmued unmodified could result in a considerable loss of 
both extracellular and intracellular cation It is not known 
whether salicylate in any way interferes with this renal 
tubular response A clear understanding of the disordered 
acid base balance m saheyhsm is essential for although 
bicarbonate administration facilitates the excretion of 
salicylate its indiscnmmate use could produce serious tetanic 
convulsions (Rapoport and Guest i945a) Confusion is 
however widespread and a recently published textbook of 
medical treatment (Birch 1950) includes a nomogram pur 
porting to define the dose of bicarbonate needed for correc 
tion of the acidosis of acute saheyhsm 

Lutwak Mann (1942) described many effects of salicylate 
on cellular metabolism and also investigated the reducing 
substances appearing in the unne dunng salicylate 



Jan 20 1951 


CORRESPONDENCE 


BlUTTOI 


139 


administration It is certain that m addition to such priitnry 
effects of salic>lale many disturbances of cellular chemistry 
will result from the induced secondary alkalosis In this 
respect it is interesting to recall that Haldane (1924) found a 
reduced glucose tolerance and gi> cosuria in states of alkalosis 
produced expenmentally by either voluntary hyperventilation 
or bicarbonate ingestion It is thus conceivable that the 
diabetic type of glucose tolerance curve found by Cochran 
e! al in their patient on salicylate therapy was the result of 
the respiratory alkalosis produced by the drug A state of 
relative starvation resulting from anorexia might more 
readily explain both the negative nitrogen balance and the 
reduced glucose tolerance — 1 am etc 
Manchester S W STANBURY 

RrnjuscEs 

Birch C A (1950) £mergencies in Medical Practice Edinburgh E and 
S Livingstone Lid 

Graham J D P and Parker \\ A (1948) Qua t J Med nj 17 153 
Guest G M etat (1942) Amer J D i Child 64 200 

Rapoport S and Roscoc C (1945) J dm Invest $4 770 

HaJdane J B S Wiggleswortb \ B and \\ oodro^s C E (1924) Proc 
To\ Soc B 95 15 

Lutwak Mann C (1942) Blochem J 36 706 

Rapoport S and Guest G M (1945) J dm In\est 24 759 ‘ 

Reid J (1948) Quart J Med ns 17 139 
—— Watson R O atidSptoull D H (1950) lb\d IS I 
Stanburj S W nndThomson A E (195!) Tobe published 


Cusbing’s Syndrome and Aspirin 

Sir — In their interesting paper (December 23 1950 

p 1411)1 B Cochrin R D Watson and! Reid refer to 
the occurrence of a reducing material in the urine It rna> 
be that this material is a conjugate of acetylsabcyhc acid 
4\nd glucuronic acid 

The appearance of increased amounts of glucuronic aad m the 
unne after salicjlate therapy \>as first reported by C Tollens* 
and C Tollcns and Stem * Csonka* reported the conjugation 
of bentoic acid \Mth glucuronic aad m pigs and later Quick 
did a good deal of tsork on glucuronic aad conjugation mth 
benzoic aad and its cten\atives including sabeybe acid iortho 
hjdroJiybenzoic acid) m dogs and man Wagreich Abrams and 
Harrow* estimated that 5% of benroic acid was conjugated as a 
giucuronidc in humans while Kapp and Cobum* estunated that 
2S% of sodium salicylate was excreted m humans m combination 
with glucuronic aad These compounds have not been isolated 
from human unne However it seems hkcly that sabcylic acid 
glucuronider^is a diglucuronide in which there is an ether bnkage 
between one molecule of glucuronic acid and the hydroxy! group 
of sabeybe aad while the other molecule of glucuronic aad is 
conjugated by an ester linkage with the carboxyl group of 
salicylic aad In each case the aldehyde reducing group of 
glucuronic acid is mvohed in the linkage and hence the glucu 
ronides are primarily non reduang Howe\cr while the ether 
linkage is alkali stable the ester linkage is very readily hydrolysed 
by alkali and consequently ester glucuronides reduce Benedict s 
solution directly In the case of acctylsaUcylic aad of course the 
only possible linkage with glucuromc acid is an alkali labile ester 
linkage Since reduction of Benedict s solution m these cases is 
due to glucuronic aad naturally the phenomenon is not repro 
duced by the addition of salicylates thcmsches to ibc unne 

It IS of course obvious that although the exaction of 
glucuronides of this t>pc may account for the appearance 
of reducing matcnal in the unne it docs not exclude the 
possibilitv of simultaneous true glycosuria — I am etc 

Guttow John Paul 

RtTERtNCrS 

iTotlens C Hoi<pc-Se}l Z 1909 6 t 95 

t sndSiem F ibid 1910 64 39 

> CjonU FA/ bid Chem 19.4, 66 545 

‘Quick A J Ibid 19.6 67 477 ibid 19 6 69 549 ibid 1932 85 189 
ibid 1932 8$ 83 ibjd 1932 97 >.03 
‘ W acreich H Vbrams A and Harrow B Proe Soc exo Slot JV Y 
1940 45 46 

•Kapp E. XL and Cobum A F / biot Chem 1942 14S 549 


Lung Abscess and Sboii. Therapj 

Sir —I hive read with interest vour annotation (December 
16 1950 p 1377) discussing the relationship of lung abscess 
to cleciro-convulsive thenipv During the last four jears 
I have worked at a large mental hospital where extensive 
use of ECT IS made m the treatment of depressive s>n 
dromes Despite the fact that several thousand electro 


shocks have been administered during this period I am 
aware of only one case of lung abscess which might have 
arisen from the shock therapy Even in this case a true 
bill could not be returned against the ECT since the 
patient had been both spoon and tube fed on innumerable 
occasions dunng the three >ears before her death from 
coronary thrombosis and lung abscess 

Two other cases of lung abscess and one case of purulent 
bronchopneumonia occurred during the four jear period 
under discussion but two of the patients thus affected had 
not at anj time been given ECT The third patient had 
received a single shock at least seven months prior to the 
appearance of the lung abscess An t ray picture taken 
four months before the development of the abscess had 
shown clear lung fields It may well be significant that 
three of these four cases had been tube fed al various 
times and in two the time interval between lube feeding 
and the development of pulmonary sepsis vvas verv close 
(days or weeks) Furthermore in one of these cases large 
numbers of Bad coli were present in the sputum a fact 
which suggests that a small quantity of milk may have 
entered the trachea 

It IS interesting to record that to the best of my know 
ledge no case of lung abscess has occurred during the last 
four years among patients attending the insulin shock 
therapy clinic where glucose tube feeding is a routine 
procedure 

These facts suggest that in psychiatric practice a much 
greater risk of lung abscess is involved m tube feedmg 
debilitated and resistant patients milt, than m the 

routine use of ECT It would seem wise however to 
refrain from giving ECT in the presence of infected 
gums and loose teeth 

A study of the incidence of lung abscess m epileptics 
might throw further light on the role of post convulsive 
inspirauon in the aeuology of pulmonary sepsis —I am, etc 


Thiouractl or Vertigo Epidcmica’ 

Sir— I vvas interested in Dr E Meulengracht s suggestion 
(December 30 1950 p 1493) that the symptoms which 
developed in a case under treatment with thiouracil and 
which were attributed by me to the drug were m fact 
caused by an attack of vertigo epidemica or neurolaby 
nnthitis epidemica 1 cannot agree 
Vehtigo epidemica is not so far as I know a common 
complaint m this country and I myself am not familiar with 
it under this name but if its symptoms are similar to those 
that I have described they are those of labyrinthine disturb 
ance and therefore common to any disease affecting that 
organ whatever the cause In the case recorded I felt 
justified m atinbuting the symptoms to thiouracil because 
they canie on at a tune when other toxic manifestations - 
usually appear during the course of treatment with this drug 
Moreover they' receded when it was withdrawn Another 
important feature is that nystagmus persisted and still 
persists two years later This I imagine does not happen 
in vertigo epidemica it certainly has not done so in those 
cases of acute labyrinthitis unassociatcd with haemorrhage 
and progressive deafness and presumably infective in origin 
that I have observed — I am etc 
Bnrhum C BaRRINCTON PrOWSE. 

Sweat and Adrenal Function 
Sir — In your annotation (September 16 1950 p 667) you 
suggest that a test for use in the clmical laboratory for 
determining the chlonde content of sweat might be useful 
as certain observers believe that the concentration of salt m 
the sweat bears a close relationship to the salt active steroid 
production of the adrenal cortex For some time I have 
been mvestigatmg the sweat excreted on the hands of 
normal and rheumatoid anhntic patients many of whom 
usually have clammy palms A detailed account will be 
prepared for publication but meanwhile the following points 
may be of interest 



140 Jan 20, 1951 


CORRESPONDENCE 


' British 
Mrdicai- Journal 


1 The technique though simple is reliable, and the esti 
mation being restricted to a small easily accessible area of 
the skin IS suitable for routine clinical use 

2 Separate estimations are made of total water, chloride 

and urea ' 

3 It IS suggested that as the salt content may be supposed 
to be related to the production of salt active steroids the 
urea estimation may similarly be indicative of the produc 
tion of sugar active steroids, which also control protein 
catabolism — I am, etc 

Hanosate A WOdDMANSBY 


" Doctors for Boys’ Oubs 

Sir — May I through your columns issue an appeal ’ The 
London Federation of Boys Clubs is\bout to launch a 
medical scheme This is m effect encouragement for regular 
routine medical inspections of the members of the clubs It 
has been found m practice that much good comes of these 
examinations Some clubs already have such a practice in 
operation but it is hoped to extend it widely That such a 
scheme should work it is necessary for doctors to take part 
voluntarily in the club life for a minimum of approximately 
two hours in an evening every three weeks There are 
many added ways in which such a doctor can be of great 
help to the many clubs m London, and these together with 
details of the scheme are contained m a short booklet which 
will be sent to any doctor asking for one It is hoped that 
' this letter may recruit those interested or willing to help 

One detail will be mentioned here It is hoped to issue a 
standard card for recording the results of such inspections and 
u IS felt that in time these might be of great medical and statistical 
value If the experience of such work (applying more to the 
younger doctor) is added to this factor, it nwll be seen that the 
ultimate good of the scheme is not entuely one sided Younger 
practitioners on the house staffs of London hospitals are just as 
welcome as the more permanent local pracutioners who may hve 
near a particular club 

It is wished to make two things abundantly clear Fust the 
scheme is to be m no sense a sick parade but a senes of routine 
medical inspections Second that the boys own doctors under 
the N H S are never to be by passed or made redundant No 
one expects these busy practitioners to carry out routine inspec 
tions on apparently healthy adolescents and when any disorder is 
detected they will always be approached 

It IS entirely unnecessary to state what worth while bodies 
the London Boys Clubs are especially m these days Any 
doctor helping in the smallest way would give much pleasure 
and might give invaluable help which would be most deeply 
appreciated — 1 am etc 

Frank Faikner 

Hon Medical Adviser for the 

l»ondOQ S E 1 London Federation of Boya Clubs 


POINTS FROM LETTERS 

■psychology in the D P M 

Dr A FolfwSON (London N 15) wntes I have frequently 
heard it expressed as an individual opinion by vanous consultant 
psychiainsts that psychology as a subject for the D P M 
(Diploma m Psychological Medicine) examination is academic to 
an unnecessary degree A recently pubbshed book wntten by 
a past examiner as a guide to the examination shows the academic 
trend to a distressing degree The greater part of the volume 
deals xMth the older systematic psychology of the philosophers 
Inore usefully relegated to a history of psychology as m the 
excellent Nolume by Professor Flugel May 1 mvite through 
your columns collectne action by those who have reached senior 
status to end this archaic situation ? 

Dead Bodies in \\ater 

Dr A Garme (Halifax) writes I have been on hobday this 
New ^ ear near the banks of the Tay A farmer fnend called 
and m the course of conversation happened to mention the came 
of an old Dundee boatman and added Once when we were 
rowing past the mouth of a tidal creek old Davy pointed to it 
and said Monv a body Ive pu ed oot o there the men face 
doon and the women face up 


Obituary 


Sir ARTHUR HALL, MD, FRCP 
Sir Arthur Hall died at his home m Sheffield on Janu 
ary 3 at the age of 84 For many years he was the 
leader of the profession in Sheffiel^, not only by the 
accident of seniority but much more because he was a 
natural leader and commanded the complete confidence 
of his colleagues 

Arthur John Hall was educated at Rugby School, 
Caius College Cambridge, and St Bartholomews Hos 
pital, graduating M B , B Ch m 1889 He worked for 
a year in general practice with his father in Sheffield 
but after his appointment 
as assistant demonstrator 
m physiology m the old 
medical school m Surrey 
Street he decided to de 
vote himself to hospital 
and consulting work, and 
)n 1890 was appointed to 
the honorary staff of the 
Sheffield Royal Hospital 
At that time the medical 
school m Sheffield had 
been m existence for 60 
years , but its life had been 
precarious, and its future 
was uncertain Hall threw 
himself with enthusiasm 
into teaching and organiz- 
ation, and through good 
days and bad — always an optimist — struggled on confi 
dent that the school would one day come into its own 
Jn 1897 the school was incorporated along with the 
Firth College and Sheffield Technical School as the Shef 
field University College At that time he was lecturer 
m physiology and secretary of the clinical committee 
and was very actively engaged m the negotiations which 
culminated m the incorporation ^ 

Before long, overtures were begun with a view to 
obtaming a university charter, and he planned, and very 
largely directed, the transformation of a small local medi 
cal school into a university department There were ups 
and downs, and there were times when the whole scheme 
of advance threatened to collapse , but he never lost 
heart He not only planned but did much of the work 
himself He occupied various teaching posts until some 
one else could be found to do the work He resigned 
the chair of physiology m 1898 in favour of Professor 
C F Myers Ward In the same vear he became pro 
fessor of pathology and resigned m 1905 m order that 
Professor Louis Cobbett could be appointed He was 
largely instrumental at this period in obtaining for the 
growmg medical school generous benefactions, notably 
the Arthur Jackson Chair of Anatomy in 1896, which 
was fir^t occupied by Dr Addison now Lord Addison, 
and the Favell Physiological Laboratory in 1897 A 
charter was granted to the University of Sheffield m 1905, 
which was opened ii) that year by King Edward VII 
In 1928 the university, m recognition of Hall s services, 
conferred on him an honorary doctorate of science 

Hall was dean of the medical faculty from 1911 to 
1916 and professor of medicine from 1916 until his 
retirement m 1931 In that year a gift of over £500 
subscribed by his colleagues and medical friends was 




Jan 20, 1951 


OBITUARY 


Burmn 

Medical Jouiuhal 


141 


handed over to the universitv to endow research In 

1935 he received the honour of 1 nighthood, and in 

1936 he was presented with his portrait which now 
hangs in the councd room of the university 

He was the architect of happy and cordial co opera- 
tion between the various Sheffield hospitals and it was 
at his instigation that a club was formed composed of 
the honorary staffs of all the voluntary hospitals It is 
now known as the Arthur Hall Club As a teacher he 
gained the respect and admiration of his students and 
by his example impressed upon them the dignity and 
importance of their calling It was not for nothing that 
successive generations of students spoke of him affec- 
tionately among themselves as Lord Arthur He was 
always concerned for the welfare of his younger col 
leagues, helped them in their difficulties encouraged 
them in their professional work, and looked after their 
interests when abroad on war service His own services 
and distmctions were not limited to his native city In 
1904 he was elected a Fellow of the Royal College of 
Physicians and subsequently served the college as exam 
iner, councillor, Lumleian lecturer (1923) and senior 
censor (an exceptional honour fora provincial physician) 
He did work of great national importance on the Radium 
Commission, as a member of the Industrial Health Re 
search Board, and as chairman of a committee of the 
Medical Research Council on pulmonary dust diseases 
In 1924 the year he was president of the Section of 
Medicme at the Annual Meeting of the B M A he was 
also made president of the Yorkshire Branch Another 
honour which fell to him was the presidency of the 
Association of Physicians of Great Britain and Ireland 
in 1931 He was an external examiner for many univer 
sities mcluding Oxford, Cambridge, London, Man 
Chester Glasgow, Leeds, Birmingham, and Bristol In 
addition to all these activities he found time to do 
original work, and his most notable contnbution to 
medical knowledge was his work on encephalitis lethar 
gica His observations on this disease were made mainly 
in Sheffield during and after the first world war and arc 
embodied in what is now a standard work on the subject 

He was a man of very wide culture His chief interest 
outside medicine was probably music He was a very 
able musician and it is said that if he had chosen music 
as a profession he would have achieved great heights 
but early in his career he reluctantly came to the con 
elusion that there was a certain incompatibdity between 
the concert platform and the work of a consulting physi 
cian He had a fine sense of humour but it was never 
exercised at the expense of others with it he embel 
hshed his lectures and speeches which were always 
models of what lectures and speeches should be 

Sir Arthur Hall is survived by a son and a daughter 
His wife, whom he mamed in 1900, died m 1945 We 
have lost a great figure in medicine, probablj greater 
than we realize, and all those who knew him have lost 
a generous and charming friend — A G Y 

CHARLES ERNEST WEST FR.CS 
Mr C E West consulting aural surgeon to SL Bartholo 
mew s Hospital, died at his home in Budleigh Salterton 
on January 1 aged 77 

Charles Ernest West was educated at Merchant 
Tavlors School Crosbv and Balliol College Oxford 
to which he obtained a classical scholarship He gamed 
a first in classics and then became interested m science 
cspcciallv chemistrv and under the tutorship of Sir John 
Conrov who had founded the school of chemistrv at 


Balliol, he obtained another first in natural science He 
now made up his mind to go in for medicine, and, 
remaining at Oxford read anatomy under Arthur 
Thomson and physiology with Professor Burden 
Sanderson He left Balliol in 1897 entering St Bar 
tholomews Hospital with the senior open scholarship 
in science, and next year passed the primary fellowship 
examination (R C S ) He qualified MRCS, LRCP 
in 1900 and also graduated B M His future career was 
assured when he was awarded the Brackenbury surgical 
scholarship and Sir George Burrows prize and was 
elected house surgeon to Mr Alfred Willett then senior 
surgeon of the hospital In 1902 he was admitted 
F R C S and was made a junior demonstrator of 
anatomy, regarded in those days as a probable step 
to candidature for some future vacancy on the staff 
Sir Holburt Waring was head of the anatomical depart 
ment and it was no doubt through his initiative that 
West was encouraged quite early to start specializing 
in diseases of the ear, rather than follow the course of 
genera! surgery 

This was the beginning of a period of renaissance at 
St Bartholomews, which became evident with the re 
building of the out patient department and improve 
ments in the special departments West was appointed 
chief assistant to Mr A E Cumberbatch, who for 20 
years had been aural surgeon and he held this appoint- 
ment for five years before being elected aural surgeon 
on Mr Cumberbatch s retirement 3Vhethcr in out 
patients m the wards, or m the dissecting rooms and 
pathological laboratory, he worked unceasingly with 
the guidance of Sir Frederick Andrevves and Lord 
Horder to carry out researches in bacteriology of 
diseases of the ear to which hitherto little attention 
had been given He published several pafiers on his 
personal observations, in the hospital reports and else 
where Mr Cumberbatch, proud of such an enterpris 
ing and enthusiastic assistant, encouraged him in every 
way to gain experience and practice in the surgery of 
the car He developed skill as an outstanding operator, 
and as he admitted, he received inspiration from the 
works of Sir Charles Ballance and Sir William Macewen 
Before long practically all patients admitted to the hos 
pital with mtracramal infections, if due to ear disease, 
were referred to the aural department for treatment 
He was the new author of Diseases of the Ear in 
Gask’s edition of Walshams Surgery and was co 
author, with Mr Sidney Scott, of a book enbtled Opera 
Uons of Aural Surgery now out of print, written 
chiefly for house surgeons and junior specialists In 
the Section of Otology of the Royal Society of Medicine 
he played an active part Among many contributions 
was a joint paper, written from personal experience on 
the surgery of the labyrinth which was the first of its 
kind in this country 

West had built up a large and successful hospital and 
private practice and he was under 50 when he decided 
to retire and leave London He was a brilliant conver 
sationalist and writer and a connoisseur of good things 
He enjoyed golf and badminton, but more than in these 
was his delight in sailing and motor boating, especially 
during the earlier years of his retirement to Flushing 
near Falmouth During the second world war he lived 
at Sturminster Newton, m Dorset where he became the 
medical officer of a local Home Guard battalion In 
the first world war he had held a Temtonal commission 
in the R.AMC, working at the Camberwell Hospital 
where Sir D Arcy Power was commandant 



142 Jan 20, 1951 


OBITUARY 


Britisb 

Medical Jourjial 


After 1945 he moved to South Devon, keeping up his 
interest in gardening and the countryside Though his 
health was not too good, he could still enjoy motoring 
and twice visited Denmark He also retained his interest 
in music, hterature, and in reviewing books — even some 
of the queerest His writings for the Press were usually 
anonvmous and nearly always on non professional sub 
jects West had a keen sense of humour and was an 
excellent sjieaker His first wife died some years after 
their marriage in 1908 His second wife was Miss Kath 
leen McCrossan who was his constant companion to 
the end He had no children — S R S 

EBB v/rites Charles Ernest West was a leading 
member of the team of ear and throat surgeons who in 
the period around the first world war made Bart s the 
greatest school for the two specialties combined that 
existed in the kingdom I gave anaesthetics for him 
before the war and was his houie surgeon and then 
clinical assistant after, and I loved him as did all those 
who were responsible to him for their work He had 
a wonderful loyalty to his team If a man was doing 
his best West would take the blame for anything that 
went wrong and he would back his junior against any- 
one on earth 

He was a great teacher, able to make ear surgery 
appear simple He had a very powerful mind and a 
vigorous body, and his teaching was always phrased in 
striking and memorable English I have watched sur- 
geons in several countries, but I have never seen his 
equal in technical skill His courage was outstanding 
If operation was a patients only hope West would 
operate no matter how slender the hope might be His 
speed cquld be astonishing when it was needed I have 
seen him do a good radical mastoid and open a cerebellar 
abscess in an unconscious patient in 13 minutes 
He retired in 1921 at the age of 48 and went to Fal 
mouth There he used to work a six ton cutter off the 
rocky coast single handed Eighteen months later he 
- tore everv muscle off a tendo Achillis jumping for a 
shot at badminton This put an end to his sailing, and 
he took to what he called water motoring , but he never 
complained ' He retained his vigour and interest in life 
to the end and was a most amusing correspondent All 
mv working life I have tried to follow in his foot- 
steps when dealing with a surgical problem or with my 
juniors He was a man I shall not look upon 
his like again ~ 

Sir LEONARD PARSONS, MD, FRCP 
FRCOG FRS 

Mr Seymour Barling writes To have had Leonard 
Parsons as a friend for over 50 years was a rich expen 
ence in life Not a few of those who attended his 
memorial service in the Birmingham pro cathedral 
and who had been his fellow students and colleagues 
throughout a long life felt a loss greater than the man 
himself as if some spirit that sustained him had been 
lost to them and left them the poorer for its going 
Those of us who knew him in his earliest years as a 
medical student realized that he brought with him into 
the school those salient qualities of mind and character 
that were to stand him in good stead throughout his 
life These basic qualities came with him from his 
simple home background with a strong religious disci 
pline Thev remained with him essentially unchanged 
as his guide and inspiration for his life s work 


Rather shy and abrupt in manner as a young man,, 
and appeanng at first-to stand a httle aloof, he did not 
make fnends easily and even from his many friends 
few became his intimates but these remained so for 
life and in them he had complete trust and confidence. 
Outside this small circle his normal academic life was- 
carried on with zest in his work and in his athletic activi- 
ties, the two most important of which were rugby foot 
ball, in which he played for the Aston Old Edvvardians,. 
and cross country runmng, in which he was an expert 
and well known exponent, attending many meetings in 
Birmingham and the Midlands By the time he was a 
prosector in anatomy in his third academic year it was 
obvious that he was becormng an outstanding student 
forming one of a group of men who at that time 
emerged from the Birmingham medical school and 
who all m various degrees became distinguished in 
their professional life 

The period he spent at the Children s Hospital, Great 
Ormond Street, was undoubtedly a, turning-point m his 
life Before going to London he had been house 
physician to Dr Arthur Foxwell at the Queen s Hospi- 
tal, Birmingham and Parsons often acknowledged the 
debt which he owed to him and to Dr James RusselL 
of Birmingham, for the inspiration and grounding they 
gave him in clinical medicine At this time it would 
seem that his interests were wholly in general medicine, 
and It wasjvnly after his work at Great Ormond Street, 
where he came under Stills influence, that his lifelong 
interest m diseases of childhood emerged About this 
time he undertook his first serious research, in associa 
tion with Tyrell Grey, on the fundamental changes 
underlying the condition of shock, on which the Arris, 
and Gale Lecture was based He was associated with 
Still in some of the earliest cases of congenital pyloric 
stenosis to be treated successfully, and thts led to his- 
interest m problems of child nutrition, which expanded 
later mto his studies and researches in coeliac disease 

In lookmg back it is interesting to study some of 
the milestones which started him along the road which 
he trod so successfully, and I have a feeling that the- 
child as a patient made a deeper appeal to him as a 
subject for clinical study than the more sophisticated 
adult patient and he was happy mdeed to find his life s 
work amongst those whose interests made such a strong 
appeal to him The keynote to his character was 
simplicity and sincerity, and he did not allow himself 
to be distracted from his mam path by the fret of 
modem life In many ways he possessed the great 
quahUes of some of the most zealous and distinguished 
of the Victorians who accomplished their Iifes work 
by an immense capacity for hard work and a burning 
zeal for achievement To this he added all the tech 
mque of modern research, gradually teaching himself 
the art of writing and expounding fluently that others 
might be inspired to carry on the work which he found 
so satisfying 

A D writes May I add a brief but very personal 
tnbute to the memory of Leonard Parsons As an 
old friend of his I have the most grateful recollections 
of his manv kindnesses to me and to my patients, his 
generosity to the latter being always unlimited I well 
remember one occasion on which he was attending me 
during a short illness On his first visit seeing that I 
was worried about my (general) practice during m> 
enforced absence from work he immediatelv offered 
to carrj on part of the practice for me This when 



Jan 20, 1951 


OBITUARY 


BRiiroi 

VtEDlCAt JOUXJvO, 


143 


one considers his preoccupation svith a busy consultant 
practice shows what manner of man he was, and for 
that reason I am very ghd to put it on record 
Our deepest sympathy goes to Lady Parsons in her 
bereavement 

GOSTA FORSSELL, MD 
Professor Carl Gustaf (Gosta) Abrahamsson Forssell 
the eminent Swedish radiologist, died in Stockholm on 
November 13, 1950, in his 75th year He was bom at 
Aspcboda Sweden, and educated at Upsala and at the 
Karohnska Institute, Stockholm where he qualified in 
medicine in 1906 He proceeded M D in 1913 From 
1906 to 1908 Forssell directed the institute of surgical 
radiology at the Serafimerlasarettet Stockholm In 1908 
he took charge of the central radiological institute and was 
chief phjsician at Radiumhemmet from 1910 to 1926 He 
held the chair of medical radiology at the Karohnska Insti 
tute from 1916 to 1926, becoming professor ordinarins 
in that year In 1936 he was appointed professor of 
diagnostic radiology a post which he held until 1941 
when he became professor emeritus Forssell s early pub 
lications were principally on the radiological anatomy 
of the alimentary tract, but his later work on the radio 
therapy of cancer earned for him an international repu 
tation The Stockholm method of radium treatment 
of uterine cancer, as carried out at Radiumhemmet vras 
also devised by him Forssell published upwards of 
200 papers and was the founder of Acta Radiotogica 
which he edited from its commencement in 1921 until 
his death In 1928 he presided at the second Inter- 
national Congress of Radiology at Stockholm On the 
occasion of his 65th birthday a fund of 100 000 kronor 
svas placed at his disposal for research — the Gosta 

Forssell Research Fund He was the recipient of many 
honours both at home and abroad in 1939 he was 
elected a foreign corresponding member of the B M A 
and as recently as July last he was elected to the hono 
rary fellowship of the Roval Societv of Medicine 


We record with regret that Surgeon Lieutenant D A 
Knock RN was killed in action in Korea towards the 
end of last year Douglas Alexander Knock studied mcdi 
cine at the London Hospital graduating MB B S in 1945 
After holding appointments as house physician and clinical 
assistant at the London Hospital and house physician at 
the Southend General Hospital he joined the Royal Naval 
Volunteer Rescrae Early in 1949 he obtained a permanent 
commission m the Rosal Navy He met his death when 
attached to the 41 Independent Commando Royal Marines 
during operations with United Nations forces in North 
easicrn Korea 

J N H J wntes 1 first met Dougcie Knock dunng 
the war when-hc was working as a student houseman at a 
buss hospital in the South of England Although still 
a student he was one of the mainstays during those diffi 
cult times accepting with good cheer and performing with 
surpnsingls mature abilits any task howeser new to him 
He was soon a \cr\ competent anaesthetist and would have 
done well had he remained in this specialts I came to 
know him well when he was a house phssician He had an 
inlense sense of duts a deep respect for his patient as a 
person and a great sense of humour WTien he joined the 
R N \ R his letiers were a source of endless amusement 
because he was so well able to appreciate the ridiculous 
elcmeni in all life s actisities After demobilization he was 
restless and not the gas fnend he had been and soon we 
heard that he had re.unied to the Navs I am sure none 
of his friends were surpnsed to hear that he ssas in Korea 
with a commando unit of the Mannes and it was with them 


that he lost his life It is a tragic loss to his friends and to 
medicine and I feel sure that there is a story of quiet 
gallantry behind this announcement that may remain tin 
sung Douggic was a most loyal friend who made 
people sery happy He leaves us however some Very 
cherished memories and although m\ son will miss his 
godfathers more tangible gifts I shall be very proud to 
tell him about Dougcie in later years. 


Medico-Legal 


THE INSANTTV DEFENCE IN DIVORCE 

[From Oor Medico Legal CoRREsroNOENT] 

A wife went out for the evening leaving her husband with 
their young daughter She returned to find the room barn 
caded the girl strangled and the husband recovenng from 
the effects of an unsuccessful attempt to gas himself He 
was tried for murder found guilty but insane and sent to 
Broadmoor In a statement to the police made on the day 
after the crime he said that he had planned it weeks ahead , 
he was afflicted with creeping paralysis due to a bad habit 
continued from childhood and had transmitted this disease 
to his daughter and so had decided to kill her and himself 
In rational letters wntten from pnson he expressed great ' 
contntion for the grief he had caused to his wife and parents 
He IS not incurably insane and may in the future be released 
The wife petitioned for divorce on the ground of cruelty 
and the husband by his guardian ad litem entered the 
defence that at the material time he knew neither the nature 
nor the quality of his acts nor that they were wrong and 
was not responsible for them. 

Mr Justice Pearce was thus faced' with the hitherto un 
solved problem of whether insanity is a good defence against 
a charge of cruelly in a divorce petition Apart from the 
insanity the wife had an unanswerable case There can be 
no greater cruelty to a woman than the killing of her child 
and she had suffered very serious injury to her health and 
nerves and would derive mental relief from dissolution of 
the marriage 

The reports contain quite a number of cases dealing with 
the point but none is conclusive Courts have not agreed 
on whether intention is a necessary ingredient of the matri 
momal offence of cruelty and in any event no court has 
ever found the insanity to have been of such a degree as 
to negative intention The matter is complicated by the 
question whether the M Naghten test applicable to crime 
should be used in cruelty cases also A person accused of 
crime who seeks to escape responsibility on the ground of 
insanity must prove either that he did not know the nature 
and quality of his act or that he did not know that it was 
wrong 

Mr Justice Pearce remarked that in criminal matters 
where the object is punishment such a defence is obvi 
ouslv necessary in a just society but it is not a safe analogs 
to assume that justice requires it in matnmonial matters 
Here the duly of the court to interfere is intended not to 
punish the husband but to protect the wife and so the 
question it has to decide is whether the wife could with 
safety to life and health live wath the husband now To 
withdraw from the ambit of legal cruelty conduct that is 
intolerable but due to insanity would make the court power- 
less to help in cases where help mav be most needed 
Thcoreticallv to include it might also cause hardship ' but 
since the wife has presumably been unable to tolerate the 
mamage tie.and has wished for divorce the husband would 
be unlilelv to attain happiness by maintaining ihe tie 
Moreover since such a defence has in no reported instance 
ever been made out on the facts its existence would not be 
of much practical benefit The judge therefore held that 

'tiKeck V Lissael 19'0 2 All E R., 233 




144 Jan 20, 1951 


MEDICO LEGAL 


British 

Medical Journal 


the insanity defence was not open to the husband and 
granted a decree to the wife, both because he could not 
find that insanity has ever been clearly established as a 
defence to a petition based on cruelty and because such 
a defence does not in his opinion accord with the true view 
of the law relating to cruelty 
However in case his view of the law should be reversed 
on appeal, Mr Justice Pearce dealt with the question 
whether the husband had proved the degree of insanity 
necessarj to establish absence of responsibility He con 
sidered that the second part of the M Naghten test, whether 
or not the husband knew that he was doing wrong, was very 
unsatisfactory in measuring misdeeds so dependent on the, 
circumstances and personalities of the parties as acts of 
cruelty Things may be cruel m particular circumstances 
and between particular persons that are not at the time of 
their commission known to be wrong The Court of Appeal 
has ruled out the substitution of the word cruel for the 
word wrong in the M Naghten test a ruling >vhich in 
Itself IS further evidence of how unsatisfactory such a test 
IS In cjvil matters the courts both of common'law and of 
equity apply the first part of the M Naghten test, whether 
the person alleged to be of unsound mind knew the nature 
of the act This the judge thought would be reasonable 
In the present case it was agreed that the husband knew 
the nature and quality of his acts Moreover even if the 
knowledge of wrong properly forms part of the test the 
husband had not proved clearly, or at all, that he did not 
'know that his acts were wrong and, as his conduct would 
nave been unlawful even if the delusions had been true, he 
could not escape liability for it Therefore even if the 
M Naghten test is fully applicable to such cases — which in 
the judges opinion it is not — the result would still be the 
same and the wife would obtain her decree 


Universities and Colleges 


UNIVERSITY OF OXFORD 

In a Congregation held on November 18 1950, the degree of 
D M was conferred on D S Parsons 

The following medical degrees were conferred on December 16 
1950 

D M — J F Monk J C Pease 

B M — J P Single M J V Bull, G P Burn *I B Denny, 
B S Freeman J R Goldmg, W D E Hamilton, *R H HiU 
D E Hone Ruth Lister J G Millar, C G Miller H E 
Milligan R G Mitchell R M Moms Owen, E F H Murphy 
J K Pearce Constance M Ridiey Jane M Robinson, Gillian 
Rowe Dutton G M Scott, *Barbara Sellman Jean McI Smellic, 
G T Smerdon Mrs Diane L Spencer J G Wallace 

Professor A D Gardner DM FRCP FRCS and 
Professor E G T Liddell DM F R S have been appomted 
chairman and Mce chairman respectively of the Faculty of 
Medicine and Professor W E Lc Gros Clark DSc, FRCS 
F R S , chairman of the Faculty of Biological Saenccs for the 
academic >ear 1950-1 

Applications for the Horatio Symonds Studentship in Surgery 
for 1951, of the value of about £200 a year must reach the 
Registrar of the UniNcrsity Clarendon Building Oxford by 
March 31 

N Rosen (Rounfihay School) has been elected to a War 
Memorial Medical Scholarship at Umversity College Oxford 
♦In absence 


UNIVERSITY OF ST ANDREWS 
William Leslie Burgess C B E M D F Jl C P Ed has been 
appointed to the newl> instituted James Mackenzie Chair of 
Public Health and Social Medicine in the Unnersity from 
April 10 Dr Burgess was appointed assistant medical officer 
of health for Dundee m 1913 becoming medical officer of health 
for the at> fi\e vears later Since 1918 he has been a member 
of the stair of the UniNcrsity of St Andrews first as lecturer m 
public health and in fc\crs and later as reader in public health 
Dr Burgess has aUo served on man> departmental and inter 
d partmcnial committees of inquiry 


' UNIVERSITY OF LONDON 

Thc’^following candidates have been approved at the examinations 
indicated 

M D — Branch I (Medicine) D M Abelson M Atkinson 
A G Beam G A Bedwell J D Blarney, S O Boldy, L 
Brotmacher F G Campbell H E Claremont R S C Couch, 
J S Crowther, L Cudkowicz, A E Doyle C J Earl, T R L 
Finnegan, P Freedman C N Grainger P C Hams (Mark of 
Distinction and University Medal) A R Hamson A Hollman 
G Howells P E Jackson C L Joiner D A Kok, M J Livera 
J Luder J C Macaulay R A Moir, C D Routh B Schwartz 
L G Scott L V Sthyr P P Turner A Venner, R L Ward 
R G Welch Joan C Wells R R Willcox I Yentis Branch II 
(Pathology) Naomi Datta, Deborah Domach C H Gray (Mark 
of Pistinction and University Medal), W J Hanbury A B Hitl* 
G R F Hilson, J D O D Lavertme G L Le Bouvier, A J M 
Reese R B H Tierney Branch III (Psychological Medicine) 
A J P Oldham Branch IV (Midwifery and Diseases of 
Women) J G Dumoubn D W James J C S Leverton 
Branch V (Hygiene) D J Davies RAG Smith 
M S — Branch I (Surgery) A Elton, T W Rowntree 
The following candidates at the London School of Hygiene 
and Tropical Medicine have been approved at the examination 
indicated 

Academic Postgraduate Certificate in Public Health — 
Lily G Arumugam, IC M Basu, Ji P Brazil Carol W Buck 
D H D Burbndge C G Burges^ T W Carnck C S Chou, 
M J Colbourne A H R Coombes, J D Cottrell D E 
Culhngton, G M Curtois R G Davies LEA Dearberg 
M Doraisingham H El iNagar, A G Farr, M A Fawkes 
L V R Fernando, P S Fuller A Girby, Y G Gupte 
Margaret I Hendne P R Henson F R T Hollins J G S 
Holman, I J Jeffery W H Jeffrey, E F E Kellar E H Lamb 
N Leitch r M Maegregor, D H Mackay G P Merson, G A 
Mott, See Yook Ng G A R Perera R Perumal, W D 
Ratnavale F G Sembeguya E S Sidey L Silverstone G A 
Steele, Julie S Suleiman, Shwe Thwin, T Visuvalingam A S 
Wallace i 

UNIVERSITY OF. MANCHESTER 
The Council of the Umversity has approved regulations for the 
award of the Alfred Lucas Blam Memorial Scholarship in 
Pharmacy established under the will of the late Mrs M E Blam 
for the encouragement of research m pharmacy and allied 
subjects The first offer wiU be made in September 

UNIVERSITY OF LIVERPOOL 
The following candidates have been approved at the examinations 
indicated 

M D — J W L Edwards, Elizabeth Rees 
M Ch Orth — J Blockey, L Bonnm V K Drennan, K S 
Fan L Henry, J H Hicks T MeSweeney F Machanik, J B 
Maloney M R Reddy, A M Sallam, H O Williams 
Final M B Ch B — Part III (Old Regulations) G M Barnes 
Monica T Barry, Winifred Billmgton, Cynthia J Bladon, 
Elizabeth J Coope H S Evans T K Hardy D H Jones 
Mary W Malone Eileen P O Mahony C W R Pyne H 
Shecter Sheila M Ward Marjorie J Williamson Passed in 
separate subjects J C Holden (Medicine and Surgery) 

D P H — Part I B Devhn M Doherty, G Fairclough 
Wilhelmina N Gaye W A Glynn B Hamilton H M Thomas 
J Vignoles 

Certificate in Public Health — P J Burke Alta F Stout 

NATIONAL UNIVERSITY OF IRELAND 
The followmg candidates at University College Galway have 
been approved at the examinations indicated 
MB BCh B AO— Mary E Doyle J M Fahy, J F 
Finnegan A K Forde B J Foy Sarah L Gavigan J J 
HoHoway P K Joyce D Kelleher J V Loughlin C Lydon 
Catherine M McDermott K U Moran ^ Cecily M Moms 
P J O Hara Maeve T Treacy G P Walsh 

QUEEN S UNIVERSITY OF BELFAST 

The followmg degrees and diplomas were conferred on 
December 20 1950 

MD — R D N Blair B MullaUy B Blewett 
MB B Ch B a O — C G Alexander S A Agnew 

Elizabeth F Bennett J B Bowden W A Bojd C F Brennan 
T D Brown J M R Campbell Janet C Davidson P J Devlin 
D A Elliott N P Ellison Patriaa E Ferguson A G Fullerton 
W J Glover F Hillman S R A Hogg T Horner D W 
Ingram D H Johnston A Jones Dorothea Kelso Mea W 




Jan 20, 1951 


UNIVERSITIES AND COLLEGES 


Pwnm 

Mo CM. JOVUMAl 


145 


Kelso W J Kemohan Frances E W Kinnaird A L Kirkland 
H Koreniager R S Lindsay Doreen E Linlon C R Locker 
J C H Loughridge M J Lyons W T E McCaughe) E 
McFall M J McKenna Ediih M McKinney A G McKnighr 
Frances M McQuilty W N McWiniam R G S Malone V J 
Marmion J E H Mercer N G Metruslry H A Millar, G 
Moles M H Moles S Moore J F O Sullivan G C Patterson 
J N Patterson ACC Pinion Norah I Rottgcr J L Russell 
I McC Todd Mary Upnchard W G Wade J A kVeaver C R 
Whiifield J S Willman, Sheila M Wilson H G Wright Sandra 
Wyhe 

C P H — A C Darrah R Logan F V Maclaine S H Moore 
P N Newsam W T Orton W J Patterson 1 Simpson E M 
Wells 

royal FACULTY OF Pm SICIANS AND SURGEONS OF 
GLASGOW 

Professor L S P Davidson will dtlivcr the Finlayson Memorial 
Lecture in the Hal! of the Faculty (242 St Vincent Street 
Glasgow) on Wednesday January 24 at 5 p m His subject is 
The Malabsorption Syndrome All medical practitioners arc 
mvited to attend the lecture 

ROYAL COLLEGE OF OBSTETRtCfANS AND 
G1 NAECOLOGISTS 

Ar a icccnt meeting of the Council of the College with the 
President Professor Hilda Lloyd in the chair Mr Geoffrey 
Kesnes and Dr R J Minnitt were formally admitted to the 
Fellowship of the College 

The President ms appoinied to represent the College at the 
fifth Centenary Celebrations of the University of Glasgow 
Lcvcrhulme Scholarships is re awirded to L W Cox MB 

FRCS MRCOG J C MrClure Browne MB BS 

MR COG and D C A Bevn MB Ch B MRCOG 
The following candidates from Australia and New Zealand were 
elected lo*the Membership Lois E Benson A D Byrne M 
Connaughton E W Duncan J M Farrar F G Favaloro R C 
Gordon A M B Grant G H Green W R D Giaffiihs A L 
Hellesirand R E Hemsiey T O Hollywood W G Jasper 
A R Long R H Macdonald Flla A N Macknight LOS 
Poidcvin N H W Sasby J R Sherwan W L Sloss K F 

Tarlinion H R Thomson Helen C Thomson T W Vorrath 

Marjone R Walker Alice Whcildon 
The following candidates from New Zealand were awarded the 
Diploma in Obsieines T J Oust Icy R R Grigor R G 
Gudex G C Liggms Diana Monuomery, R A Warren 

FACULTY OF RADIOLOGISTS 
The following candidates base saiKiicd the Fellowship Board at 
the IdSO examination for ihc Fellowship Radmtheran D G 
Braihenon B A Sioll R C Tudway Radiodiagnosn A N 
Gaballa W S Holden O B Lode 

3 

EProCMrOLOGICAL ^OTES 

Smallpox at Brighton 

Up to noon on January 16 Ihcrv have been 30 cases of 
smallpox in the Brighton area Light cases have died The 
cases have come from three mam foci 

(1) Bt\fndean ffoipimf — All the initial cases from here 
were employed m the ward in which the second case was 
nursed for 10 daw Eight hclonced to the dav or night 
nursing staffs and two were ward maids Of ihcse three 
nurses and the two domestic workers have died During 
the past few days four other cases have occurred in the 
hospital These were connected more or less directly with 
the personnel in the affected v.ard 
(21 LaiirJn —The cloihinc of the original case veas sent 
here and from this six employ ccs have contracted the disease 
Two laundry workers have died 

IT) Telephone Ctr/mnee— The second case was cmploved 
here and two further cases have come from this source 
In Ihe past week f ur cases have tsecn no iffed not directlv 
related to the thre- mam foa they were not under survcit 
lance when Ihev developed' the disease Rather tenuous 
circumstances mav relate these cases to existing foci but 
the position is nor clear Olher cases o*' this tspe hasc to 
be exp'Cted The infection disseminated from th' three foci 
before sinci survcii!an“c was set up is onU now becomme 
manifest 


Although the disease is confined to Ihe Brighton area and 
there is no sign of spread to other parts of the United King 
dom the stiaciesl vigilance is still imperative throughout 
the country 

Influenia 

The statistics given below indicate an increased incidence 
of influenza throughout England and Wales In the week 
ending January 6 there were large increases m pneumonia 
cases and deaths both in England and Wales and m the_ 
great towns while there was also a considerable increase 
in influenza deaths in the latter — from 102 in the preceding 
week to 458 in the week referred to here 
This sleep rise reflects an unusually high prevalence of 
the disease which may continue during coming vvecks Of 
these deaths 339 out of the 45g occurred north of a line 
roughly drawn from Crewe through Sheffield to Ihc Humber 
and were largely associated with outbreaks on Merseyside 
and Tyneside here the disease was generally mild in form 
though highly infectious and the deaths with few excep 
tions were among elderly people 
There was also an increase in influenza deaths in the 
London and South east Region compared with the preceding 
week while increases of some degree occurred in all regions 
It would appear that particularly in the north and north 
west there is some increase in Ihc seventy of Ihe disease 
The evidence of the numbers of new claims to sickness 
benefits also indicates an increased influenza prevalence 
especially in Ihe north and north west In these two regions 
combined such claims totalled 74 844 in the week ending 
January 2 compared with 31 371 in the week ending 
December 19 1950 For the whole country the claims 
nearly doubled themselves in the same period 
It would appear that m the areas in the north and north 
west originally attacked Ihe epidemic has passed its peak 
But there is evidence of an increased prevalence in various 
towns and cities not so far seriously affected — for example 
Manchester Bolton Salford Wolverhamplon Sheffield 
Norwich — and possibly this indicates a spread of the 
northern epidemic Similarly in Carlisle (Cumberland) 
and Kendall (Westmorland) there were suggestive rises in 
insurance claims 

In the Southern Eastern and Western Regions there is 
an increasing general prevalence of influenza in many areas 
with scattered localized outbreaks here and there but 
nowhere so far as is known at present do situations exist 
similar to those of the past fortnight in many cities and 
towns in Ihc north west During Ihe week ending January 6 
deaths certified as due to influenza in London county 
numbered 40 This docs not suggest or even portend 
epidemic proportions 

The position in Ihe south up to Jantiarv J6 remains un 
certain But there was serological evidence of virus A 
infections and virus A wias isolated from garglings in one 
cave durinc Ihe week ending janiian 13 
The following cases of and deaths from pneumonia and 
influenza have been reported in the great towns 



4 \\ 

ii>n 

IB'Jl Z5‘U 

iW’l 

j9/l2' 

16 

73 iz'sojizi 

6/1 

Pneuttenja 

! zsy 

^61 

3»3 

302 

1 

1 

1 1 
347 J 

374 

l3« 

j vm 


Deaihj 

• 19S 

m 

in 

07 ( 

1 193 

ZJS 1 


: 35t 

1 3S3 

DO 

In^4cn?a 

Dcati:* 

1 .9 

t :o 

1 *** f 

24 1 

; 7s| 

i »1 

33 

! 54 ■ 

i 

j joa 

45S 


Totals from ibe first wc-k of the scar in the great towns 
compared with the preceding two years are as follows 


1 ITv’ I 19'a I 1951 




146 Jan 20, 1951 


EPIDEMIOLOGY SECTION 


BjtmsH 

Medical Journal 


Thd following Table shows notifications of pneumonia 
— primary and influenzal — in England and Wales- 



4/11 

11/11 

18/11 

1 25/11 

I2/I2 

9/12 

16/12 

23/12 

1 

,30/12 

6/1 

Pneumonia 

433 

465 

558 

490 

1 497 

573 1 

684 

647 

962 

1774 

Corresponding 
week 1949 

419 

534 

667 

1 710 

1 1 

715 , 

734 

1 

1 

676 

634 1 

1 

84Z 

1 

1 120 


The following weekly claims have been made on the 
Ministry of National Insurance Week ending October 31 
1950 127,245 November 7 144446, November 14, 

148 497, November 21, 147,415, November 28, 145 783, 
December 5 142 011 , December 12, 141 403 December 19, 
128 842 December 26 87,277 (four days only) January 2 
1951, 246 223 

Regional totals of influenzal deaths in the great towns 
in the week ending January 6, and rates per million (in 
parentheses) were Northern 103 (83) Eastern 9 (119), 
East and West Ridings 6 (2 6) London and South east 76 
(10 8) Northwestern 230 (63 7) Southern 4 (4 9) North 
Midland 8 (7 6) Wales 3 (4 5) Midland 11 (4 8) South' 
western 8 (8 3) 

Influenza deaths in the great towns by age groups were 
Under 1 2 1-14 1 15-54 58 55 and over, 357 Deaths 

in London Administrative County — 40 — are not included in 
this age grouping 

Influenza Abroad 

There is news of an extensive outbreak of influenza in 
Belgium It IS said to be mild in type with a low mortality 
No virus has yet been identified In Holland influenza is 
also prevalent and there is evidence that it is due to virus A 
possibly of the A pnrae type of the Swedish outbreak 
Denmark is apparently still suffering from a high preva 
lence and it is reported that there is a heavy epidemic m 
Greenland with an attack rate of about 90% The disease 
is probably prevalent in northern Spain but information at 
present is indefinite 

Poliomyelitis 

Notifications of poliomvelitis in the week ending 
January 6 were paralytic, 37 (36) non paralytic 10 
(17) total 47 (53) Figures for the previous week arc 
given in parentheses Notifications in the corresponding 
week of the previous four years were 1947 10 1948 

58 , 1949 20 1950 54 The notifications in the first week 
of 1951 are therefore little different from those of the 
corresponding week in 1948 and 1950 Each of these three 
years are comparable in that they followed years of high 
incidences of the disease , 

The Inumber of notifications of acute poliomyelitis (not 
corrected for revision of diagnosis) in England and Wales in 
the second half of 1947 1949 and 1950 are shown in the 
following Graph (reproduced from the Registrar General s 
If'eef.ly Return for England and Wales 1950 No 52) 


Notifiable Diseases in 1950 

The chief features of the returns of notifiable diseases in 
Encland and Wales dunng the year were the very high inci 
dencvs of whooping cough acute poliomyelitis and dysen 
ten The trend of whooping cough was notable for the 
high level in the last weeks of the year when the notifica 
tions were the largest ever recorded for this season There 


IS some doubt whether the increase in the number of notifi 
cations represents a real increase iri the incidence of whoop 
ing cough Possibly more cases of whooping cough are 
seen by medical practitioners since the operation of the 
Health' Service 

The trend of the notifications of acute pohomyelitis in 
1950 differed from that recorded in 1947 the rise began 
earlier and fell more slowly from a smaller peak in 1950 
than in 1947 (see Graph below). The total notifications of 
measles is not exceptionally high because of the low level 
in the beginning of the year but the number of notifica 
tions in the second half of the year was larger than ever 
recorded for any third and fourth quarter The incidence 
nf dysentery was high throughout the year the number of 
notifications ranged from 149 to 461 per week during the 
first quarter, from 213 to 457 in the second quarter, from 
137 to 278 m the third quarter and from 169 to 1,214 in the 
fourth quarter 

A further substantial fall in the number of notifications 
of diphthena was recorded in 1950 but the rate of decline 
IS falling For 1948, 1949 and 1950 the number of notifica 
tions was 75, 62 and 58% of the number recorded in the 
preceding year A companson of the records of 1950 with 
recent years is made in the Table below 


Cases IQ England and3^ales 

1946 

1947 

1948 

1949 

'1950 

Scarlet fever 

SVhooping cough 

Diphthena 

Measles 

Acute pneumonia 
Memngo''occal tofections 
Acute poliomyelitis 
Dysentery 

Eotenc (typhoid and para 
typhoid fevers) 

57 614 
92 028 
18 156 
154 826 
36 106 

2 627 
703 
8441 

I 367 

60 524 
94 241 
10 528 
399 461 
34 348 

3 147 

9 251 

4 179 

880 

75 460 
145 878 

7 903 
396 841 
31096 

1 971 

2 175 

5 587 

873 

71 753 
102 516 

4 929 
384 361 
34 624 

1 5S6 

6 850 

4 819 

1 I3S 

66 852 
157 714 

2 858 
366116 
30 7M 

1 745 

8 699 
18 135 

654 

Deaths m the 126 Great 
Towns 






Tuberculosis 

• 

• 

11 715 

10 877 

8 934 


2 629 

1723 

608 

3 090 

1 859 

Acute poliomyelitis 

• 

• 

139 

415 

501 

Whooping cough 

443 

522 

434 

329 

250 

Diphthena 

258 

130 

100 

51 

27 


• Not avatJaWe 


Infectious Diseases 

Dunng the week ending December 30 1950, large nses 
were recorded in the' number of notifications of measles 

3 140 and acute pneumonia 315 while a decrease of 333 was 
reported for dysentery The largest nses in the incidence 
of measles were 632 in Lancashire and 366 in London The 
number of cases of acute 'poliomyehtis notified was the 
same as in the preceding week , the largest returns were 

4 in the counties of Devon, Lancashire, and Warwick 

Dysentery 

The largest returns for dysentery in the week ending 
December 30 1950 were Lancashire 120 (Southport C B 
29 Middleton M B 24, Liverpool C B 15 
Oldham CB 12) Leicestershire 119 (Leices 
ter CB 93) Yorkshire West Riding 69 
(Earby U D 14) London 44 (Finsbury 9, 
Paddington 8), Essex 26 (Romford M B 19) 
Shropshire 26 (Shrewsbury MB 11) Glam 
organshire 24 (Swansea C B 20) Stafford 
shire 24 (Stoke on Trent C B 13), Cheshire 
23 (Wallasey C B 10) Sussex 21 (Eastbourne 
C B 17) Middlesex 21 (Edmonton M B 8), 
Surrey 19 (Croydon C B 13), Durham 16 
Northants 15 (Kettenng M B 14), Devon 
shire 13 Cumberland 12, Southampton 11, 
Warwickshire II 

Week Ending January 6 
The notifications of infectious diseases in England and 
Wales dunng the week included scarlet fever 923 whoop 
ing cough 5 009 diphtheria 38 measles 21 688 acute pneu 
monia 1 774 acute poliomyelitis 47 dysentery 834 smallpox 
13 paratyphoid fever 1 typhoid fever 4 In the great towns 
the deaths attnbuted to influenza numbered 458 


1 700 
5 600 
^ 500 
I 400 
£ 300 
£ 200 
S 100 
g 0 






K 

— 


— 

— 1 — 1 — 1 — 










POLIOMYELITIS 




Ri 

m 

BB 

Hj 








■1 

m 

m 

■ 

IBI 

IB 

Hi 

lull 





■ 

■ 

s 

■1 


Hi 

IS 

8i 

B 

Hi 





Bi 

ws 

m 







Hi 



B 

S 

s 

B 








SB 


B 

B 

B 














V/EEK NUMBER 


5? 



JaS 20, 1951 


EPIDEMIOLOGY SECTION 


RKJTttn 

MtDICAL JOtTLVxL 


147 


No ^2 

iNrrcnous diseases and wal STATisncs 

\Vc pnni below a Sumrrary of Infecliou Di^ascs and Vital 
Statistics in the British Isles dunne the v\cet ended December 30 
Figures of Pnncipal Notifiable Disease forihe»eek and those for the corfc- 
iponding Week, last year for (a) Enplant and \Va1 s (London included) fb) 
e - (d)rire (cl Northern Ireland 

rece dfd under each Infect cut 
rgl nd and N\a1es (Including 
■ (clThc 16 principal tossn* m 

(e) The 10 principal tomns In 

Northern Ireland 

A dash ^ denotes no cases a blank s'^ace d notes disease not notifiable or 
no return available 

Medical Novs 


Medals for Blood Donors 

The Minjslr> of Health announces that awards arc to be 
presented to long service donors m the National Blood 
Transfusion Service the Scottu^h National Blood Tnnsfusion 
Assocnlion and the Greater London Red Cross Blood 
Transfusion Service and to other donors who have given 
repeated gifts of their blood To qualifj a volunteer must 

Disease 


1950 



|l947 (Corresponding^ eeV) 

1 (a) 1 

(b) 

1 (c) 

( ^ 

(el 1 

(O 

(b) 

(c) 

(d) 

(e) 

tions of blood since Septem ** 
ber 1939 Women donors 

will receive a brooch and jf Z ^ 

men a lapel badge The f 

design of the award which j ^ ^ 3 ^ / 'jj 

has bccil personally ap L ^ v ^ ' 

proved by His Majesty the L 1 ^ 1 

King shows two interlock \ / 

ing hearts surmounted by \\ / 

the Crown and resting on V ^ / / 

a scarlet background There N 


Meningococcal fnfcc 
tion 

Deaths 

1 

2 

n 

1 1 

3 

- 

1 

22 

2 ' 

_2,1 

- 

- 

\ 

Diphthena 

Deaths 

4ii 

1 1, 

3 

n 

1 

— 

102 

1 

10 

1 


1- 

1 

V .\ 

n \ 

Dysentery 

Deaths 

691 

44' 

104 

1 

j 

5 

197 

1 9 
1 

113 

K 


1 

Encephalitis acute 
Deaths 

7 

— 

*“ 

— . 

1“ 

' 


— ' 

1 1 


7 

Erssipclas j 

Deaths 



19 

6 

1 


I 

24 

i ^ 

7 


Infective enienils or ' 
diarrhoea under 

2 yean 

Deaths 

26 



1 1 

10 7 

( It '* 

20 


4 

25 

1 

2 

iward silver giU for at 

least 50 donations silver for 25 donations and bronze for 
10 donations There are now nearly 400 000 donors in the 

Measles* 

Deathst 

17 468 

Il92- 

1 

io-» 

81 

80 

1 978 

47 

21 

56 

1 

145 

National Blood Transfusion Service and it is estimated 
that about 200 donors will be entitled to the stiver gill award 

Ophthalmia oeona 
torum 

Deaths 

21 

3 

,0 

- 

28 

3 

5 

> 

- 

SOOO lo the siher and 70000 to the bronze Anyone who 
thmls he is entitled should apply on the special form obtain 
able from the regional blood transfusion centre where he is 
at present enrolled from a local organizer or at a blood 

ParatjTihold fever 
Deaths 

6 

I 

— 


z 

2 

z 

1(B) 

z 

z 

Pneumonia iniluen 
zal 

Deaths (from In 

962 

64 

23 


6 

842 

59 

22 

6 

11 

IntcmatjODal Research on Rheumatic Fctcr 


nuenra)* 

102 

8 

3 

1 


28 

5 

4 

1 

— 

The American Council on Rheumatic Fever of 

the 

Pneumonia primary 
Deaths 

383 


269 

A 

17 

3II 

^’1 

362] 

1 1 

44 

18 


American Heart Association is co ordinaling an investiga 
tion at 12 centres in Britain Canada and the USA in 

Poliomyeiius acute 
Deaths) 

53 

5 

i ^ 

1 ^ 


— 

66 ' 

81 

1 

1 

1 

3 

1 

which all patients with acute rheumatic fever treated with 
ACTH or cortisone during 1951 will be followed for at 

Puerperal foer 
Deaths 


1 i 




— 




least three ycirs lo sec whether these hormones actually 
'll cr the course of the illness and prevent rheumatic heart 

Puerperal pyretia t 
Deaths 

38 

n 

5 


4 


4 

6 

— 

1 

disease or whether they merely suppress symptoms Hic 
makers of ACTH and cortisone have each given $5 000 

Relapsing feser I 

Deaths ' 

— : 

i-i 



1 


1 



— 

towards the cost of organizing the co operative study and 
arc providing the large amounts of the two substances 

Scailct fcsxr 

1 0*6 

62 

ISI 

52' 

4 

2^27 

1 159 

255{ 

til 

196 

required In Britain the Medical Resenreh Council is 

Dcaihst 


I-I 

— j 


— 


1 

-1 

— 

— 

financing the research in association with hospitals 

at 

Smallpot 

Deaths 

4 

— 

— 


' Z 

— 

1 — 

, — 

— 

1 — 

Newcastle Cardiff Sheffield Taplow and I ondon which 
arc undertaking the work In Cnnadi the Hospital for 

TVpl'o d feser 

Deaths 

Z j 

= 1 

— 

h 

I 

25 

1 si 

-1 

-1 

-1 

I 

Sick Children m Toronto is being helped by the Omdian 
Rheumatism and Arthritis Foundation The National Heart 

T>Thus feser 

Deaths 


|-| 

i 

i 

— 

— 


-I 

= 1 

z 

Institute of the UJ5 Public Health Servue is helping research 
m New ^orl Boston Denver and Chicago and in addi 

WTioo^mg-cough 

Deaths 

3 690 
7 

3*3 

4 

44*. 


25 

t OIS 
n 

34 

II 

60, 

f 


55 

' 1 

tion the Armed Forces Epidemiological Board and the 

U S Air Force are supporting a studv at a A F base 

in Wvominc 

Deaths fO-1 year) | 

277 

29 


20 


^5 


'1 

j’i 

17 

Deaths (etc uding i 
siillbithsl 1 

Arrjal d_ath rate 
(per 1 t>i0 per* 
tonsil mg) j 

,3J 

1 

1 1 

1061 

fS^ 

m] 

196 

13« 

5.56lj 

1 

14 2 

194^ 

, 1 
12-0, 

167 

Actiologj of Rheumatoid ArthnUs 

It will be recalled Nee British \fe'iica} Journal 19^0 
] 799 and 826) that the Scrntific Advisory Committee of 

List b nbs 

Ar-ual rate per 

1 (XXt prsoas 

li 1 s 

1 5-S 

1 

«411 

169 ! 

; 4 

1 

1 

j-o 

”1 

i 


8*0 25«’ 

1 ' 

17-4 17 8 

223 

the Empire Rh-iimalism Council reccntlv earned out a 
carcfiillv conlrol!'*d and statistically analv“scd invcstiption 
into this problem and showed nol onlv that th'Tc is no good 
evidence for nanv so-called environmental causes but that 
the clinical pattern is of a svstcmic disca c and not of a 
pure arthntis The full repon has row been publi'^hed as 
a supp^cmnl to the Anrcis of the Rhenrve ic Diseases and 

IS obtainabl* pnee 75 6d^ from this oFre, 

Han cun Soactv of London 

Sti r bs 

Ra e per 1 000 
to a1 b 'lbs (fV i 
c J- n- s 1 INsmt 


1 1 

"1 

i \t 

1 

: i 


\ 

1 

1 

1 

1 



Measles is aa no ha'' t in ind and the it a~is a « tb n o'r an 

a~pTV*“ati''S c~ y 

+ D a b fnr-i — »ea 1-s a*»J v.ar t fr»xf f-' E“‘i: ird and Wain London 

(t^— -v t 1 Or en • ) »4 1 r be p '' vh-d 

• l-wlji pn— a-y f->e— j f-.* Lng a-id and Waicr Lenioa (a-rviss^ ire 

J Th of «5,a •vs v>r“ve t a*»d po i3 

Erg i*si a*vd W ai*v. (»--i - era i^r c-nr* y) are cc*xi*-.r»w 

J t*>-l,KSn po'^^'a <’f»— ^£> Ejv * 1 ^ ar- W aW aod Eire 
^ Pnnarv p-irr— ro 1 if-*'- e tn E-'t. 

i for 

Th- Bu-hstop Browre Pnzi for 19'0 has been award'd to 
C. J Gave, for his essay on The Maragent'M o' t'-' 
Hcpeloss Ca'c " 




148 Jan 20, 1951 


MEDICAL NEWS 


Bvtob * 
Medical Joumul 


Ministry of Food Announcement 
After February 28 national dried milk will no longer be 
available to patients suffering from steatorrhoea coeliac 
disease and tropical sprue From that date ^t will nor 
maily be reserved for children under 2 years old to whom 
It IS supplied as an alternative to liquid milk The Ministry 
will, however consider granting supplies of national dried 
milk to children over 2 years of age or to expectant mothers 
if they present appropriate medical certificates 

St John Ambulance Bngnde 

Mr Frank H Edwards of Shrewsbury has been appointed 
Surgeon in Chief in succession to Dr Corbet Fletcher of 
Hampstead, who has resigned Mr Edwards is consultant in 
obstetrics and gynaecology to No 15 Hospital Group 
(Shropshire) and to Shropshire and Montgomeryshire County 
Councils Dr Marcus M Scott, of London, has been 
appointed deputy surgeon in chief 

English Patients for Norwegian Sanatoria 

Dr Claude Lillingston writes from Bergen to point out 
that, with a population of only 3 2 millions, Norway is now 
provided with some 5,000 beds in sanatoria coast hospitals 
and homes for the tuberculous and many beds are un 
occupied and ready to receive patients from abroad at 
charges which are moderate partly because the Norwegian 
currency is soft Inquirers interested m the subject should 
communicate with the medical superintendent Mesnalien 
S'lnatonum Lillehammer Norway or the secretary general 
of the Norwegian National Association against Tubercu 
losis His address is Nasjonalforeningen mot Tuberkulose 
Incogmtogate 1 Oslo Norway ^ 

Manchester Medical Society 

At a meeting of the Section of Medicine on December 6 
1950 Dr G G E Smyth gave a paper on ‘ A Re examina 
tion from the Clinical Standpoint of some Aspects of Dis 
seminated Sclerosis 

In Brief 

Dr H P Himsworth secretary of the Medical Research 
Council is visiting West and East Afnca December 29- 
February 11 to inspect vanous colonial research units con 
cemed with virus diseases malaria leprosy and trypano 
somiasis and hot climate physiology 

Dr Chaloem Puranananda, secretary of the Thai Medical 
Research Council and director of the Pasteur Institute Bang 
kok who has been touring Western Europe^ is spending 
three weeks in Bntain January 3-24 visiting medical re 
search institutions and studying recent Bntish developments 
in electron microscopy 

COMING EVENTS 
Association of Clinical Pathologists 
The 45th scientific meeting of the Association of Clinical 
Pathologists will be held in the Meyerstein Lecture Theatre, 
Westminster Medical School Horseferry Road London 
SW on Friday and Saturday January 26 and 27, at 
9 30 a m and demonstrations will be given at the Royal 
Army Medical College Millbank S W from 9am on 
January 26 to 1 p m on January 27 A private business 
meeting will be held on January 25 

Contraceptive Technique 

A lecture and demonstration (on living models) on contra 
ccptive technique will be given by Mane C Slopes PhD 
at the Mothers Clinic 108 Whitfield Street London W on 
Thursday February 8 at 2 30 p m Tickets must be obtained 
imadvance as space is limited 

Neurology and Eve Diseases 

Professor Torsten Sjogren of Stockholm will deliver a 
lecture on Hereditary Neurologic Diseases Assoaated with 
Certain Eve Diseases at the Institute of Neurology 
National Hospital Queen Square London W C on Friday 
March 9 at 5 p m 


SOCIETIES AND LECTURES 

A fee 15 charged or a ticket is required for attending lectures 
marked ® Application should be made first to the institution 
concerned 

Monday 

•Institute of Child Health Hospital for Sick Children Greai 
Ormond Street London WC — ^January 22 5 pm The 
Future of the Child Health Services by Professor W S Craig 
Institute of Psychiatry Maudsley Hospital Denmark Hill 
London S E —January 22, 5 30 p m lecture demonstration by 
Dr E Stengel 

Institute of Urology — (I) At St Paul s Hospital Endell Street 
London W C January 22 1 1 30 a m Non gonococcal 

Urethritis by Dr A H Harkness ,2pm Neoplasms of 
the Urethra Penis and Scrotum by Mr D I Williams 
(2) At St Peter s Hospital Henrietta Street London W C 
3 30 p m ward round by Mr J G Sandrey 5pm, museum 
demonstrations by Mr H K Vernon \ 

Medical Society of London II Chandos Street Cavendish 
Square W — January 22 8 30 p m discussion Headache 
to be introduced by Drs Macdonald Cnichley and R Bodlcy 
Scott 

Royal Eye Hospital St Georges Circus Southwark London 
SE — ^January 22 4 pm Optics (Revision) by Mr H N 
Reed 

©Royal Eye Hospital St George s Circus Southwark London 
S E — January 22 5 30 p m , Anatomy of the Eye and Orbit 
by Professor T Nicol 

Tuesday 

British Postgraduate Medic ' School 

of Hygiene and Tropical ^ ondon 

W C January J23 5 30 pj- ep b\ 

Professor E D Adrian O ivi , i iv ^ 

•Institute of Dermatology Lisle Street Leicester Square 
London W C — January 23 5 pm, Diseases of the Nail 
by Dr D I Williams 

Institute of Urology —At St Paul s Hospital EndcU Street 
London WC, January 23 10 am Stress Incontinence in 
Women by Mr Harland Rees 2 pm Diseases of the 
Female Urethra by Mr H G Hanley 3 30 p m ward round 
by Mr J E Semple 5pm Injuries Fistulae and Foreign 
Bodies in the Urethra ^ Mr H G Hanley 
Royal Eye Hospital St George s Circus Southwark, London 
S E — ^January 23 5 pm, Mistakes and their Lessons by 
Mr T M Tyrrell ^ 

Wednesday '' 

©Empire Rheumatism Council — At 41 Portland Place London 
W January 24 6 p m annual ceneral meeting 
•Institute of Dermatology Lisle Street Leicester Square 
London WC — January 24 5 pm Medical Mycology 
lecture demonstration by Dr R W Riddell 
Institute of Urology — At St Paul s Hospital Endell Street 
London W C January 24 10 a m Epididymitis Cystic 
Swellings of the Scrotum by Mr J D Fergusson 1 1 30 a m 
Congenital Defects of Testis and Epididymis by Mr D I 
Williams 2pm Congenital Defects of Kidney and Ureter 
by Mr J G Sandrey 3 30 p m Calculus Disease of Kidney 
and Ureter (1) by Mr H P Winsbury White 5 pm 
Calculus Disease of Kidney and Ureter (2) by Mr H P 
Winsbury White 

Royal Eye Hospital St Georges Circus Southwark London 
S E — ^January 24 5 p m Pseudoglwma by Mr R P Cnck 
Royal Faculty of Physicians and Surgeons of Glasgow 242, 
St Vincent Street Glasgow — January 24 5 pm The 

Malabsorption Syndrome Fmlayson Memorial Lecture by 
Professor L S P Davidson 

Thursday 

British Postgraduate Medical Federation — At London School 
of Hygiene and Tropical Medicine Keppel Street London 
W C January 25 5 30 p m Cutaneous Sensibility by 
Dr A G M Weddell 

Institute of Urology — (1) At St Paul s Hospital Endell Street 
London W C January 25 10 a m Disturbances of Miciun 
tion m Nervous Disease and Injurv by Mr A W Badenoch 
11 30 a m , Incontinence in the Male Atony of the Bladder 
Enuresis by Mr D T Williams (2) At St Peters Hospital 
Henrietta Street London W C 3 30 p m ward round b) 
Mr H K Vernon (3) At St Paul s Hospital Endell Street 
London W C 5pm Tumours of the Testicle by 
Mr H G Hanley 

Liverpool Medical Institution 114 Mount Pleasant Liverpool 
—January 25 8 p m Renal Cortical Necrosis by Dr H C 
Moore 

London Jewish Hospital Medical Society — At Medical Society 
of London 11 Chandos Street London W January 25 
3pm The Approach of the Forensic Pathologist to the 
Investigation of a Case of Murder by Violence by Dr F E 
Camps 

Medico Legal Society — At 26 Portland Place London W 
January 25 8 15 pm The CMC Hitherto and Henceforth 
by Dr Robert Forbes \ 

Royal Eye Hospital Si George s Circus Southwark London 
S E — ^January 25 5 p m Papilloedema by Dr S Nevin 


Jan 20, 1951 


MEDICAL NEWS 


BMTTSn 

Medical Journal 


149 


St AjfDREWs UNlvtRsiTY — At Lecture Theatre Matena Medtea 
Department, Medical School Smalls Wynd Dundee January 
25 5 pm The Influence of Adaptation on Host Parasite 
Relationships in Disease by f^ofcNsor W J Tulloch ^ 

St Georges Hosphal Medical School Hyde ParL Comer 
London S W — January 25 4 JO p m lecture-demonstration on 
psychiatry 

Torquay and Distthct Medical Society — At Torbay Hospital 
January 25 8 JO p m Backache Sciatica ana Ruptured 
Disks by Mr Kenneth Pndie 

University College (Phvsiology Theatre) Gower Street London 
we — ^January 25 5 la pm Physico-chemical Properties and 
Pharmacological ActiMty of Drugs by Mr F Bergcl PhD 
D Sc 

Friday 

Kent and Canterbury Hospital, Canterbury —January 26 
5 p2n clmical meeting 

London Unin'ersity — At London School of Hygiene and, 
Tropical Medicine Kcppcl Street Gower Street W C 
January 26 5 JO pm Infection and Immunity in Smallpox 
special university lecture m pathology by Professor A W 
Dowme 

Medical Society for TirE Studt op Venereal Diseases 11 
Chandos Street, London W — January 26 8 pm general 
meeting 

•Royal Eye Hospital St George s Circus Southwark London 
SE — ^January 26 5 30 pm Physiology of the Eye 

Royal Medical Society 7 Melbourne Place Edinburgh — 
January 26 8 pm The Wide* Scope of Therapeutics 
dissertation by Mr J K Stewart Kirkaldy 

Royal Sanitary Institute — At Royal Technical College Salford 
January 26 10 30 am papers The Promotion of Mental 
Health fn the Community * by Dr A Tome and Professor 
E W Andefson The Control of Infection in the Com 
munity by Dr M T Parker and f^ofessor Wilfnd Gaisford 
Temperature Control The Basic Principle of Food Hygiene 
by Mr J C Starkey 

Saturday 

Biochemical Society — At Postgraduate Medical School Ducane 
Road London W January 27 lOJO a m 293rd meeting 
Papers will be read 

British Association of Aucroists —At Royal Society of 
Medicine 1 Wimpole Street London W January 27 Ham 
annual general meeting 11 30 a m short papers will be read 

Kent Paediatric Society— At Famborough Hospital Kent 
January 27 2 30 p m clinical meeting 


BIRTHS, MARRUGES, AND DEATHS 

niRTIIS 

Browne —On December 25 1950 ■( Ncwcuile-upon Tyne to Barbara 

(formerly Cunningham) wife of Professor R C Browne DM M R C P 
t daughter*— QIzabetb Caroline 

Cantor —On January 9 1951 at the Mlddleiea Hospital London W to 
Kathleen (formerly Wallach) wife of Dr J Cantor a »on— -TimoUiy 
Jefferson 

MARRIAGES 

Abramaoo— Dods — On December 9 1950 at CoUnton Church Edinburgh 
Allan William Abramson M R C P D C H to Morag Dods 
M R C O G 

DEATHS 

Armstroos. — On December 30 1950 at 120 Glouccitcr Court Kew Surrey 
Wilfred Erne t Arbuihnot Arm irong MRCS LRCP Lieutenant 
Colonel IMS retired aged 85 

CampbefL— On lanuary 3 1951 at Dundee Peter Campbell MB of 

Scurbrae Balmcrino Fife aged 94 

CU^ — On January I 1951 Aann Catherine Oark MB B Chlr DA 
of 153 Cromwell Road London S W 
DarlvTaylor — On December 29 1950 at 3 Spencer Road South, ea 

Edward James Davis-Taylor MB B Chlr 
Droocht — On December 31 1950 Roben Smerger Albert Drought MB 
B Ch of Brabourne Bexbill-on Sea Suisea aged 79 
Matson — On December 21 1950 at Melbourne Victoria Australia Thomas 
Rhodes Matson DSO MB (Hi B late of 10 Albany Street 
Edinburgh 

Mitchell — On December 20 1950 Albert Waldegrave Mitchell MRCS 
Slanc House Mjsdalcn Road Wand worth Common London SW 
Munro —On December 25 1950 at Wlmboroe Dorset Marlorle Munro 
(formerly Cu eden) MB (^ B Corner (pottage Lower Rowe near 
Wimbome Dorset formerly of Romford Essex 
Ormsby — On December 27- 1950 at Rochford Hospital Essex Wliflam 
'' — 1 — » - D Co Mayo Eire late of 

aged 78 

Nursing Home Newport 
riavenny Moo 

I ell Peake M D of Reed 

Thatch Burpham Arundel Su sex late of China 
Platts — On December 18 1950 at 112 London Road Chelmsford Essex 
Harry Platts MRCS LRCP 

Rodeert — On December 30 1950 nt Ennerdale West Avenue Leeds 
William Rodgers MB Ch B aged 79 
Sansom — On January 6 1951 in a nursing home St Leonards Sussex 

Charles Lane Sansom CMC FRCSEd DPH aged 88 
Thomas. — On December 27 1950 at his home Wembley Middlesex Albert 
Edward Thomas MD DPH 

Ward —On December 20 1950 at New York City Gec^ge Gray Ward 
M D 

Warrlet — On December 21 1950 at 3 St German s Place Blackheatb 
London S E Robert Waller Warrick MB B S 

— On January 1 19^1 at his home Broadpark Moor Line Budlefgh 
Saltertoo Devon Charles Ernest West F R C S aged 77 


Any Questions? 


Correspondents should give their names and addresses (not 
for publication) and include all relexant details tn their 
questions « Inch should be typed JFe publish here a selec 
tion of those questions and answers v^hich seem to be of 
general interest 

Demon5trntion''of Malona Parasites 

Q — What 15 the most certain method of demonstrating 
malaria parasites in the blood of a patient suspected of 
haxtng malaria^ When should blood films be taken ^ Is 
the prior injection of adrenaline helpful^ 

A — Malana parasites can best be dcmonstrate(i in the 
blood of a patient by making a thick film on a slide stain 
ing the film with Giemsa s stain and examining it under 
the microscope A good brand of stain should be used the 
distilled water should be correctly buffered and the standard 
technique of staining followed A prolonged search ma> be 
necessary before a parasite is detected the film should be 
examined by an expenenced worker and it should be con 
firmed that the patient has recci^fcd no antimalaria treat 
mcni The species of parasite may not be recognizable in 
a thick film and can be more easily determined (if the 
infection is not too light) in a thin film 
As a rule parasites are present throughout the febnJe 
periods they arc often most numerous in the case of 
Plasmodium falciparum at the beginning of each paroxysm 
In P malanar infections parasites may occasionally remain 
undetectable for sbveral attacks and may appear only dunng 
the later relapses so if this form of the disease is suspected 
many blood films should be examined ^ 

Adrenaline as an aid to the diagnosis of malana is prob 
ably more used by Conlincrtal than British worVeiB its 
intravenous administration may cause a transient appear 
ance of parasites in the peripheral circulation and this 
procedure may therefore be helpful m doubtful cases 

Treatment of Malaria 

Q — (I) What IS the best treatment for BT and MT 
malaria ^ (2) Is proguaml ( palitdnne ) still thought of 

as highly as it wor txxo or three years ago^ (3) What is 
the best way to prevent B T relapses ^ 

A — (I) Treatment of Bengn Tertian Malana (a) In an 
indigenous population when the aim of treatment is simplj 
to control the overt attack a single dose of 300 mg 
proguanil^hydrochloridc 300 mg mepaerme hydrochlonde 
or 500 mg chloroquine diphosphate usually suffices 
Altcrrtaiivcly, full therapeutic courses may be given 
proguaml (300 mg bd for 7-10 days) mepaenne (300 mg 
tds for the first day 200 mg Ids for the second day 
100 mg tds for 5-7 days) or chloroquine (500 mg on 
admission 500 mg four hours later . 500 mg once daily 
for the next three days) 

(b) Tn individuals not frequently exposed to reinfection 
and in whom it is desired to eradicate the infection treat 
ment with paludrinc mepaenne or chloroquine will con 
trol the overt attack but will not affect the relapse rate 
Combined treaiVncnl with an 8 aminoquinoime such as 
pamaquin and a schizontocidal drug will however, con 
sidcrably reduce the relapse rate 

Examples of such combined treatment are 

1 Ouinine dihydrochlonde 10 gr (0 65 g) 

Pamaquin hydrochlonde 10 mg 
Given together tds for 10 days and 
u Proguaml hydrochlonde 100 mg 
“ Pamaquin hydrochlonde 10 mg \ 

Given together tds for 10 days 
During treatment the patient must be kept in bed and 
given pleifty of fluid Toxic effects from pamaquin arc 




150 Jan 20 , 1951 


ANY QUESTIONS? 


BRmsH 

Mnjicu. JouxjuL 


most uncommon at this dosage but include acute abdominal 
colic and cyanosis Renal complications may appear at 
higher dosage 

(2) Treatment of Malignant Tertian Malaria 
Any of the following courses of treatment will bring about 
clinical relief and possibly radical cure ' 

I Mepacnne hydrochloride 300 mg tds for 1 day 
Proguanil hydrochloride 200 mg tds for 9 days 

(The initial dose of mepacnne is introduced because of 
the probability of the existence of proguanil resistant para 
sites Where such resistance is not likely the mepacnne 
may be omitted and the proguanil given for 10 days) 

II Mepacnne hydrochloride 300 mg t d s foi 1 day 

200 mg tds for 1 or 2 days 
I , 100 mg tds for 7 days 

'll! CMoroqume diphosphate 500 mg on adnussion 
^ 500 mg 4 hours later 

, 500 mg once daily for 3 days 

The doses given above are for adults i 

All active antimalarial drugs except pamaquin are well 
tolerated by children The dosages for children are as 
follows 


1 Age 
Birth to 2 years 
3 to 5 years 
6 to 10 years 
11 to 15 years 
Over 15 years 
II Choroqume 


Paliidrwe 
25 mg tds 
50 rag tds 
75 mg tds 
100 mg tds 
adult dosage